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«5  ^  T^iizJ  /-T"  J^^i^. 


A  HANDBOOK 


OF 


Physical  Diagnosis 


OF 


Diseases  of  tlie  Organs  of  Respiration  and 
Heart,  and  of  Aortic  Aneurism 


BY 

R.  C.   M.  PAGE,  M.D., 

Professor  of  General  Medicine  and  Diseases  of  the  Chest  in  the  New  York  Polyclinic ; 
Visiting  Physician  to  St.  Elizabeth's  Hospital,  the  Polyclinic  Hospital,  and  the 
North  Western  Dispensary,  Department  of  Diseases  of  the   Heart  and 
Lungs  ;  Member  of  the  New  York  Academy  of  Medicine  ;  Hono- 
rary Vice-President  of  the  Congress  held  in  Paris,  1888, 
for  the   Study   of  Tuberculosis,   etc.,   etc. 


mixtX    ^Axtion 


NEW     YORK: 
J.   H.   VAIL   &   CO.,    21    ASTOR    PLACE 

1891 


Copyright  by 

R.   0.  M.   PAGE,  M.D. 

1889. 


PRESS   OF 

THE   rUIlLISHERS'    I'RINTING   COMPANY, 

157-159  WILLIAM   STREET, 

NEW   YORK. 


ALFRED  L  LOOMIS,  M,D.,  LL.D., 

WHOSE     THOROU&H     AND    SYSTEMATIC    TBACHIHG-^ 

AS  WELL  AS  MAISi  Y  ACTS  OF  KINDNESS,    ARE 

GRATEFULLY   REMEMBERED, 

IS  RESPECTFULLY  DEDICATED  BY 

THE  AUTHOR 


3748? 


PEEFACE 


f 

Iisr  compliance  with  the  requests  of  students  this 
vohime  is  now  placed  before  the  medical  profession. 
In  it  I  have  endeavored  to  treat  the  important  subject 
of  Physical  Diagnosis  from  a  logical  standj^oint, — the 
deductions  in  each  case  being  drawn  chiefly  from  j)er- 
sonal  observation.  By  this  means  I  have,  in  many  in- 
stances, furnished  the  all-impOrtant  missing  links  that 
necessarily  occur  in  a  mere  printed  list  of  physical 
signs,  however  ingeniously  arranged.  The  student  is 
thus  saved  much  valuable  time  that  would  otherwise 
be  lost  in  attempting  to  supply  those  links  unaided. 
Besides  a  consideration  of  the  physiology  and  normal 
anatomy  of  the  organs  involved,  brief  mention  of  eti- 
ology and  pathology  has  been  found  necessary  in  many 
cases,  as  well  as  the  proper  classification  of  disease. 

There  is  but  little  original  to  be  offered  at  present 
on  the  subject  of  Physical  Diagnosis,  but  whenever  I 
have/thought  that  I  had  cause  to  differ  with  even  the 
most  eminent  writers  on  this  subject,  I  have  not  hesi- 
tated, with  due  resjDect  to  them,  to  do  so. 

To  Dr.  Henry  Macdonald,  lol  East  31st  Street,  IS'ew 


vi  PREFACE. 

York  City,  I  am  greatly  indebted  for  the  illustrations, 
most  of  which  are  original  and  copied  from  life,  or  path- 
ological specimens. 

R  C.  M.  Page,  M.D. 

31  West  38rd  St.,  New  YpRK  City 
May,  1889. 


COI^TEI^TS, 


CHAPTER  I. 


The  Chest  in  Health— Regions— Methods  of  Physical  Ex- 
amination —  Inspection  —Palpation —  Fremitus —  Per- 
cussion— Palpatory  Percussion — Quality  of  Sound  its 
most  Important  Property,  as  compared  with  Pitch, 
Duration  and  Intensity — Auscultation — Normal  Res- 
piratory Murmur — Normal  Pectorophony,  or  Vocal 
Resonance  over  the  Chest — Other  Methods  of  Physical 
Examination — Succussion — Auscultatory  Percussion — 
Autophonia — Phonometry 1 

CHAPTER  II. 

Diseases  in  which  the  Convection  of  the  Breath  and  Voice 
Sounds  may  be  Obstructed  in  the  Bronchial  Tubes, 
and  Refracted  in  the, Lungs  as  much  as,  or  more  than, 
in  Health,  with  Corresponding  Diminution  or  Sup- 
pression of  Fremitus,  Respiratory  Murmur,  and  Pec- 
torophony— Bronchitis — Adventitious  Sounds — Asth- 
ma— Emphysema — Pulmonary  Congestion  and  CEdema 
— Certain  Forms  of  Atelectasis  (Apneumatosis)     .        .         35 

CHAPTER  III. 

Diseases  in  which  the  Breath  and  Voice  Sounds  are  Con- 
ducted with  more  Force  than  in  Health  with  Corre- 
sponding Inci'ease  of  Fremitus,  Respiratory  Murmur, 
and  Pectorophony — Bronchial  Breathing — Broncho- 
phony—Solidification  of  Lung  Tissue — Pneumonia — 


viii  CONTENTS. 

PAGE 

Pulmonary  Consumption— Cancer— Hydatid  Disease— 
Hfemorrhagic  Infarction—  Pulmonary  Hemorrhage     .  69 

CHAPTER   IV. 

Diseases  in  which  the  Breath  and  Voice  Sounds  are  Inter- 
rupted in  their  Transmission  to  the  Chest  Walls  with 
Consequent  Diminution  or  Absence  of  the  Fremitus, 
Respiratory  Murmur,  and  Pectorojihony — Pleurisy — 
Thickened  Pleura — Pleuritic  Effusion— Pyothorax  or 
Empyema —  Hydrothorax  —  Pneumothorax  —  Htemo- 
thorax — Pneumo-hydrothorax 135 

CHAPTER  V. 
Summary  of  Adventitious  Sounds — Classification  of  Rales 
— Friction  Sounds — Splashing  Sounds — Changes  Pro- 
duced by  Disease  in  the  Respiratory  Murmur  and  Vo- 
cal Resonance — Pectorophony  and  Pectoriloquy  .        .        159 

CHAPTER  VI. 

The  Heart — Outline  on  the  Chest  Walls — Position  of  the 
Valves — Normal  Sounds — Valvular  Lesions — Endocar- 
dial Murmurs,  Organic  and  Functional— Mitral  Mur- 
murs— Pericardial  Murmurs — Intra-ventricular  Mur- 
nmrs — Tricuspid  Murmurs — Aortic  Murmurs — Venous 
Hum — Pulmonic  Murmurs — Antemic  Murmurs — Endo- 
carditis —  Pericarditis —  Hydropericardium  —  Myocar- 
ditis—Hypertrophy— Dilatation — Fatty  Heart — Atro- 
phy— Exophthalmic  Goitre — Angina  Pectoris— Cardiac 
Diseases  that  Cause  Sudden  Death — Functional  Dis- 
eases— The  Sphygmograiih — Aortic  Aneurism       .        .        183 


PHYSICAL  DIAGNOSIS. 


CHAPTER  I. 

THE  CHEST  IN  HEALTH. 


Physical  Diagnosis  is  the  art  of  distinguisMng 
health  from  disease,  and  one  disease  from  another  by 
means  of  the  physical  signs  presented  in  each  case.  It 
approaches  nearer  to  an  exact  science  than  any  other 
branch,  and  may  truly  be  termed  the  mathematics  of 
medicine.  It  embraces  various  methods  of  examina- 
tion, including  the  use  of  instruments  to  be  hereafter 
described. 

The  Physical  Signs  of  health,  as  well  as  of  disease, 
are  those  that  are  to  be  recognized  by  the  examiner's 
special  senses,  particularly  sight,  touch  and  hearing. 
There  are  certain  physical  signs  characteristic  of  health 
and  others  that  belong  respectively  to  individual  dis- 
eases. 

In  order  to  understand  the  physical  signs  of  disease 
it  is  evidently  necessary  first  to  know  them  in  health. 
Then,  by  the  application  of  principles  of  well-known 
physical  laws,  a  logical  and  correct  conclusion  may  be 
arrived  at  in  each  case,  which  is  more  reasonable  than 


2  PHYSICAL    DIAGNOSIS. 

to  attempt  to  commit  isolated  facts  to  memory,  only  to 
be  forgotten. 

For  tlie  sake  of  convenience  the  chest  walls  are 
marked  ont  into  different  regions,  the  limits  of  which, 
though  arbitrary,  should  always  be  made  with  due  re- 
gard to  the  anatomy  of  the  underlying  thoracic  organs. 
There  are  an  anterior,  posterior,  and  two  lateral  regions 
of  the  chest,  and  each  of  these  is  subdivided  into  other 
regions. 

Anterior  Region. — This  is  divided  into  two  similar 
parts,  right  and  left,  and  a  middle  part. 

The  right  and  left  parts  comprise,  each  from  above 
down,  the  following  regions:  1,  suxDra-clavicular ;  2, 
clavicular;  3,  sub-clavicular  (infra-clavicular,  supra- 
mammary);  4,  mammary,  and  5,  sub- mammary  (infra- 
mammary,  hypochondriac).  The  middle  part  is  di\'ided 
into  the,  6,  supra-sternal;  7,  superior  (upper)  sternal, 
and  8,  inferior  (lower)  sternal  regions. 

The  supra-clavicular  region  is  triangular  in  shape 
and  is  situated  above  the  clavicle.  It  is  bounded  below 
by  the  upper  border  of  the  clavicle,  within  by  the  lower 
2Dortion  of  the  sterno-mastoid  muscle,  and  without  by  a 
line  drawn  from  the  inner  end  of  the  outer  fourth  of  the 
clavicle  to  a  point  on  the  sterno-mastoid  muscle  cor- 
responding with  the  upj)er  ring  of  the  trachea. 

On  both  sides  the  aj^ices  of  the  lungs  rise  into  the 
neck  above  the  sternal  ends  of  the  clavicles,  according 
to  Gray,  about  an  inch  and  a  half,  but  in  persons  with 
long  necks  as  much  as  two  inches;  in  women  rather 
higher  than  in  men,  and  on  the  right  side  than  the  left. 

The  clavicular  region  corresponds  to  the  inner  three- 
fourths  of  the  clavicle. 

The  sub-clavicular  region  (also  called  infra-clavicu- 


EEGIONS   OF   THE   CHEST.  6 

lar,  or  siipra-mammary)  is  bounded  within  by  the  edge 
of  the  sternum  (sternal  line),  without  by  a  line  let  fall 
perpendicular  from  the  inner  end  of  the  outer  fourth  of 
the  clavicle,  and  continuous  with  the  anterior  axillary 
line;  above  by  the  lower  border  of  the  clavicle,  and 
below  by  the  upjjer  border  of  the  third  costal  cartilages 
and  ribs,  corresponding  exactly  Avith  the  base  of  the 
heart.     In  order  to  find  the  upper  border  of  the  third 


■fe 


/    A 


Fig.  1. — 1.  Supra-clavicular  Region;  3.  Clavicular;  3.  Sub-clavicular;  4.  Mammary; 
5.  Sub-mammary;  6.  Supra-sternal;  7.  Superior  Sternal;  8.  Inferior  Sternal  Region. 

rib,  especially  in  fat  people,  feel  for  the  horizontal 
ridge  on  the  sternum  that  marks  the  line  of  union  be- 
tween the  manubrium  and  gladiolus.  At  this  point, 
on  either  side,  is  the  articulation  of  the  second  costal 
cartilage  with  the  sternum.  Immediately  below  is  the 
de^Dression  between  the  second  and  third  ribs,  or  the 
second  intercostal  space,  the  u^Dper  border  of  the  third 
rib,  as  well  as  lower  border  of  the  second  being  dis- 
tinctly felt.      The   right  and  left   second  intercostal 


4  PHYSICAL    DIAGNOSIS. 

spaces,  called  respectively  aortic  and  pulmonary,  have 
special  significance  in  the  study  of  the  heart,  as  Ave 
shall  see.  The  sub-clavicular  regions  are  chiefly  occu- 
jyied  by  lung  tissue,  but  the  right  primitive  bronchial 
tube,  larger  than  the  left,  more  superficially  situated  an- 
teriorly, and  given  off  higher  up,  causes  important  dif- 
ferences in  the  physical  signs  of  the  two  regions,  as  will 
be  fully  described.  The  study  of  these  two  regions  in 
health  is  of  the  first  importance,  the  more  so  as  tuber- 
cular pulmonary  consumption  usually  manifests  itself 
first  in  one  or  the  other. 

The  mammary  region  is  bounded  above  by  the 
upper  border  of  the  third  rib,  below  by  the  upper  bor- 
der of  the  sixth  rib,  within  by  the  edge  of  the  sternum 
(also  called  the  sternal  line),  and  without  by  the  anterior 
axillary  line  which  is  continuous  with  the  outer  boun- 
dary of  the  region  above.  The  heart  is  chiefly  situated 
in  the  left  mammary  region,  the  apex-beat  correspond- 
ing to  a  point  between  the  fifth  and  sixth  ribs,  one 
inch  and  a  half  below,  and  half  an  inch  within  the  left 
nipple.  Gray  and  others,  however,  place  it  two  inches 
below,  and  one  inch  within  the  left  nipple.  The  super- 
ficial area  of  cardiac  dullness  lies  almost  wholly  within 
the  left  mammary  region.  The  right  mammary  region 
extends  down  to  the  liver,  the  lower  border  of  the 
former  exactly  coiTesponding  with  the  upper  border  of 
the  latter. 

The  sub-mammary  region  (infra-mammary,  hypo- 
chondriac) is  bounded  above  by  the  ux)per  border  of 
the  sixth  rib,  below  by  the  free  margin  of  the  ribs; 
within  it  comes  almost  to  a  point  at  the  edge  of  the 
sternum  and  without  it  is  bounded  by  the  anterior 


ifeEGIOiS'S    OF   THE   CHEST.  5 

axillary  line.  The  region  on  the  right  side  is  occupied 
by  the  right  lobe  of  the  liver.  On  the  left  side,  we 
have  the  left  lobe  of  the  liver  and  the  large  end  of  the 
stomach.  The  outer  boundary  of  the  region  on  the  left 
side  corresiDonds  to  the  anterior  border  of  the  spleen 
from  the  ninth  to  the  eleventh  ribs.  Between  these 
two  regions  is  the  epigastrium. 

The  supra-sternal  region  lies  above  the  supra-sternal 
notch  and  between  the  supra-clavicular  regions.  In 
it  lies  the  trachea,  but  by  firm  pressure  downward 
with  the  finger,  the  ^^atient's  head  being  inclined  for- 
w^ard,  ]3ulsations  of  the  transverse  portion  of  the  arch 
of  the  aorta  may  be  felt,  especially  in  the  case  of  an- 
eurism. 

The  superior  sternal  region  (api^er  sternal)  corre- 
sponds to  that  x^ortion  of  the  sternum  above  the  line  of 
the  upper  border  of  the  third  ribs. 

The  inferior  sternal  region  (lower  sternal)  corresponds 
to  that  part  of  the  sternum  below  that  line. 

Posterior  Region. — This  is  divided  on  each  side, 
from  above  down,  into  the,  1,  supra-scajDular;  2,  scapu- 
lar, and  3,  sub-scajDular  (infra-scapular)  regions,  and 
between  the.  scapulae  is,  4,  the  inter-scaiDular  region. 

The  supra-scapular  region  corresponds  to  the  supra- 
spinous fossa  of  the  scaj^ula,  and  is  occupied  by  lung 
tissue. 

The  scapular  region  corresponds  to  the  infra-si^i- 
nous  fossa  of  the  scapula,  and  is  also  occupied  by  lung- 
tissue.  It  is  much  larger  than  the  former,  and  extends, 
according  to  Gray,  down  to  the  eighth  rib. 

The  inter-seapular  region  is  situated  between  the 
scaiDulfe  on  both  sides  of  the  spinal  column,  which  di- 


6 


PHYSICAL    DIAGNOSIS. 


vides  it  into  the  inter-scapular  regions  of  the  right  and 
left  sides.  It  extends  downward  to  a  line  drawn  hori- 
zontally from  the  inferior  angle  of  one  scapida  to  the 
other.  In  front  and  on  each  side  of  the  spinal  column 
in  this  region  the  bronchi  enter  the  lungs,  the  right 
bronchus  opposite  the  fourth  dorsal  vertebra,  accord- 


FiG.  2.— 1.  Supra-scapular  Region;  2.  Scapular;  3.  Sub-scapular;  4.  Inter-scapular 

Region. 

ing  to  Gray,  and  left  opposite  the  fifth,  about  an  inch 
lower. 

The  sub-scapular  (infra-scapular)  region  is  bounded 
above  by  the  lower  borders  of  the  scapular  and  inter- 
scax)ular  regions,  below  by  the  lower  border  of  the 
twelfth  rib,  within  by  the  spinal  colunui  and  outside 
by  the  j)osterior  axillary  line. 


EEGIONS    OF   THE   CHEST. 


Lateral  Regions. — These  are  divided,  right  and  left> 
into,  1,  the  axillary  and,  2,  sub-axillary  (infra-axillary) 
regions.    The  axillary  region  corresponds  to  the  axilla. 


Fig.  3.— 1.  Axillary  Eegion  ;  2.  Sub-axillary  Region. 


It  is  bounded  below  by  a  line  connecting  the  lower 
border  of  the  mammary  region  with  the  lower  border 
of  the  scapular  region ;  in  front  by  the  anterior  axillary 


8  PHYSICAL    DIAGNOSIS. 

line  and  behind  by  the  posterior  axillary  line.  They 
are  both  occupied  by  lung  substance. 

The  sub-axillary  (infra-axillary)  region  is  bounded, 
below  by  the  lower  border  of  the  twelfth  rib,  above  by 
the  lower  border  of  the  axillary  region,  in  front  by  the 
anterior  axillary  line  and  behind  by  the  posterior  axil- 
lary line.  On  the  right  side  is  the  liver,  on  the  left  is 
the  spleen  and  large  end  of  the  stomach. 

A  line  drawn  perpendicularly  downward  from  the 
middle  of  the  axilla  is  called  the  middle  axillary  line,  or 
simply  the  axillary  line.  It  is  important  in  connection 
Avith  aspiration  or  drainage  in  case  of  pleuritic  effusion, 
whatever  be  the  character  of  the  latter.  Other  lines  de- 
scribed by  authors,  but  less  frequently  mentioned  per- 
hajDS,  are  the  mammillary  line,  drawn  perpendicularly 
through  the  nipple  on  either  side;  the  sternal  line,  cor- 
responding AAith  either  edge  of  the  sternum;  the  j)ara- 
sternal  line,  drawn  between  and  i:»arallel  with  the  two 
preceding;  the  scapular  line,  drawn  vertically  through 
the  inferior  angle  of  the  scapula,  and  the  vertebral 
line,  right  and  left,  on  each  side  of  the  sj^inal  column. 

The  methods  adopted  in  the  physical  examination 
of  the  chest  are,  princi2)ally,  inspection,  palpation,  per- 
cussion, and  auscultation.  There  are  other  methods  of 
less  importance  to  be  described  hereafter.  The  use  of 
the  thermometer,  or  calormetation,  as  well  as  the  ex- 
amination of  the  sputa,  are  well-known  methods  of 
I)hysical  examination. 

I.  Inspection. 

Inspection  is  the  act  of  looking  at  the  patient,  and 
naturally  comes  first  in  order.     In  examining  the  chest 


iisrsPECTioisr.  9 

in  health  the  patient  should  ordinarily  be  strippea  to 
the  waist  in  a  warm  and  comfortable  room,  and  should 
stand  in  the  erect  position,  the  heels  near  each  other 
and  on  the  same  line,  the  arms  being  dropped  loosely 
by  the  side.  The  front  of  the  chest  should  be  inspected 
first.  For  this  jDurpose  the  observer  should  stand  di- 
rectly in  front  of  the  patient  and  at  a  convenient  dis- 
tance for  inspection. 

It  is  rare  to  find  a  perfectly  symmetrical  chest  even 
in  health.  The  right  side  may  be  a  little  larger  than 
the  left,  especially  in  right-handed  people  with  extra 
develoi:)ment  of  muscle,  as  among  carpenters  and  black- 
smiths. IN'ot  infrequently  one  shoulder  is  lower  than 
the  other  owing  to  occupation,  as  is  sometimes  the 
case  among  hod-carriers  and  tailors;  or  to  previous 
fracture  of  the  clavicle,  or  curvature  of  the  spine.  Such 
deviations  from  the  perfect  symmetry  of  the  chest  may 
be  compatible  with  perfectly  healthy  lungs.  The  apex- 
beat  of  the  heart  may,  or  may  not,  be  seen,  depending 
a  good  deal  uj)oia.  the  thickness  of  the  chest  walls. 
There  is  general  and  even  exi}ansion  on  both  sides  dur- 
ing insiDiration,  forced  or  quiet,  and  respiratory  move- 
ments are  not  usually  more  noticeable  on  one  side  than 
on  the  other.  Abdominal  respiration  is  more  notice- 
able in  men,  superior  costal  respiration  in  women.  The 
upper  part  of  a  woman's  chest  expands  more  on  inspira- 
tion than  a  man's  to  allow  for  child-bearing,  the  dia- 
phragm in  men  being  a  more  powerful  and  important 
muscle  of  resiDiration  than  in  women.  On  the  other 
hand,  abnormal  centres  of  jDulsation,  the  jpresence  of 
tumors,  abnormal  bulging  or  flattening  of  the  chest 
walls,  and  exaggerated  respiratory  movements  on  one 


10  PHYSICAL    DIAGNOSIS. 

side  with  climinution  of  those  movements  on  the  other, 
would  indicate  disease. 

For  examination  posteriorly  the  patient  may  be 
turned  around,  but  should  stand  in  the  same  erect  jDosi- 
tion.  Sometimes  a  slight  lateral  curvature  of  the  sx^ine 
may  be  noticed,  owing  to  the  greater  traction  of  the 
stronger  muscles  of  one  side  drawing  it  in  that  direc- 
tion. The  shoulders  may  not  be  on  the  same  level,  as 
already  stated.  The  scapulse  should  move  evenly  dur- 
ing respiration,  as  a  rule,  but  there  are  excej)tions.  In 
choreic  children,  for  instance,  nervous  and  hysterical 
women,  or  those  who  chance  to  be  in  a  nervous  condi- 
tion from  the  abuse  of  alcohol,  tobacco,  or  the  like,  to 
say  nothing  of  impostors  who  have  heard  lectures  on 
the  subject,  we  may  find  very  uneven  movements  of  the 
chest  walls,  and  especially  the  scaj)ulae,  though  the 
organs  of  respiration  be  j)erfectly  healthy.  The  un- 
even movements  due  to  these  causes,  however,  instead 
of  being  uniform,  as  in  disease,  usually  vary  and  change 
from  one  side  to  the  other.  When  one  side  steadily 
and  uniformly  expands  more  than  the  other  to  any 
noticeable  extent,  it  is  usually  indicative  of  disease,  as 
we  shall  see  hereafter. 

In  lateral  inspection  the  patient  should  place  the 
hands  on  the  head.  Abnormal  bulging  or  retraction 
of  the  sides  would  indicate  disease.  But  these  are  ob- 
served better  from  the  front,  or  x)osterioiiy,  than  the 
side. 

II.  Palpation. 

Palpation  is  the  act  of  feeling,  and  has  reference  to 
the  special  sense  of  touch.     It  is  the  second  step  in  the 


PALPATION.  11 

regular  order  of  examination.  It  is  usually  performed 
by  laying  tlie  jjalms  of  the  hands  on  the  patient,  but  it 
is  sometimes  convenient  to  j)alpate  with  the  ear  in  com- 
bination with  auscultation. 

The  palms  of  the  hands,  when  they  are  used,  should 
previously  be  warmed,  if  necessary,  and  then  laid  gen- 
tly, and  lightly,  on  corresponding  xjarts  of  the  chest 
walls  at  the  same  time.  This  is  usually  sufficient,  but 
some  prefer  to  apply  the  hands  alternately,  or  even  to 
cross  them,  with  or  without  closing  the  eyes,  so  as  to 
make  the  test  in  every  way,  in  doubtful  cases.  It  is 
important  that  the  examiner  should  stand  directly  in 
front  of,  or  behind,  the  patient,  according  to  circum- 
stances, in  order  to  perform  this  act  v>dth  proper  care. 
For  palpating  in  front,  the  patient  should  stand  erect, 
as  for  inspection.  But  when  palpating  posteriorly,  the 
patient  should  cross  the  arms  in  front  and  gently  grasp 
the  left  shoulder  with  the  right  hand  and  the  right 
shoulder  Avith  the  left  hand,  keeping  the  elbows  close 
in  to  the  body,  which  should  be  bent  slightly  forward. 
In  this  position  the  scapulae  are  moved  out  of  the  way 
and  the  tissues  on  the  back  rendered  more  tense. 

Vocal  Fremitus. — What  is  the  object  of  i)alpation? 
Chiefly  to  ascertain  the  presence  or  absence  of  vocal 
fremitus,  which  is  the  vibration,  thrill,  or  jarring  of  the 
chest  walls  caused  by  the  sound  of  the  voice.  And  if 
present,  to  know  whether  it  is  abnormally  increased  or 
diminished. 

Fremitus,  or  jarring  of  the  chest  walls,  may  be  pro- 
duced in  various  ways  and  is  designated  accordingly. 
If  produced  by  the  voice  it  is  called  vocal  fremitus  or 
voice  thrill.     From  the  fact  that  the  chest  walls  vibrate 


12  PHYSICAL    DIAGNOSIS. 

it  is  sometimes  called  pectoral  thrill.  As  vocal  fremi- 
tus is  the  kind  of  fremitus  by  far  the  most  commonly 
observed  and  referred  to,  it  is  often  called  fremitus 
simply,  without  being  specified  as  vocal  fremitus.  It 
is  more  or  less  generally  felt  over  the  whole  chest,  but 
more  marked  on  the  patient's  right  side,  as  will  be 
presently  described  at  length. 

Other  kinds  of  fremitus  are  tussive  (or  tussile)  fremi- 
tus produced  by  the  cough,  and  of  use  perhaps  when 
the  voice  is  much  impaired  or  lost;  rhonchal  (or  rhon- 
chial)  fremitus  caused  by  large  rales,  or  gurgles,  and 
more  or  less  localized  at  that  point ;  friction  fremitus, 
sometimes  felt  over  a  pleuritic  friction ;  and  splashing 
fremitus  produced  by  succussion  in  case  of  large  cavi- 
ties containing  air  and  fluid,  as  in  pneumohydrothorax. 
Besides  detecting  fremitus  we  may  also,  by  means  of 
ptalpation,  be  enabled  to  accurately  count  the  number 
of  respirations  to  the  minute,  should  it  be  impossi- 
ble to  do  this  by  inspection.  For  this  purpose  the 
hand  should  be  lightly  applied  to  the  abdomen  in  men, 
or  the  upi^er  j>ixvt  of  the  chest  in  women,  for  reasons 
already  stated  By  i^alpation  also  we  may  be  enabled 
to  locate  the  apex-beat  of  the  heart,  and  ascertain  the 
character,  frequency  and  rhythm  of  its  movements,  as 
well  as  of  the  radial  pulse.  To  a  very  limited  extent 
we  may  also  conjecture  the  amount  of  expansion  and 
contraction  of  the  chest  walls  during  respiration,  but 
these  are  better  told  by  inspection  or  measurement  if 
necessary.     The  surface  temperature  should  be  noted. 

To  detennine  the  presence  or  absence  of  the  vocal 
fremitus  in  any  given  case  by  palpation,  it  is  necessary, 
of  course,  for  the  i^atient  to  make  use  .of  the  voice. 


PALPATION.  13 

For  this  purpose  the  patient  should  pronounce  some- 
what loudly  the  words  "  one,  two,  three,"  during  the 
act  of  palpation,  and  repeat  them  as  often  as  necessary. 
Any  short  simple  phrase  would  answer  the  purpose,  • 
but  these  words  are  as  good  as  any  others,  and  besides 
they  have  the  sanction  of  time-honored  custom.  Some, 
however,  prefer  the  w^ords,  " ninety-nine,"  or  "nine- 
teen." The  reason  for  speaking  these  words,  or  some 
simple  phrase,  is  chiefly  because  they  can  be  repeated 
over  and  over  again  on  the  same  key  by  any  one.  This 
is  very  important.  In  ordinary  conversation  on  any 
subject  the  key,  or  pitch,  of  the  voice  being  constantly 
changed,  the  fremitus  varies  accordingly.  The  lower 
the  pitch  of  the  voice  the  more  marked,  as  a  rule,  will 
be  the  resulting  fremitus. 

It  is  important  to  understand  that  the  normal  vocal 
fremitus  is  more  marked  in  the  right  than  the  left  sub- 
clavicular region.  In  other  words  there  is  normal  ex- 
aggerated vocal  fremitus  in  the  right  sub-clavicular 
region  of  the  healthy  chest.  How  is  this  very  impor- 
tant fact  to  be  explained?  Simply  because  the  right 
primitive  bronchial  tube  being  larger  than  the  left,  a 
larger  volume  of  voice  is  conveyed  into  the  right  lung 
than  the  left. 

The  trachea,  about  four  and  a  half  inches  in  length, 
extends  from  the  lower  part  of  the  larynx  on  a  level 
with  the  fifth  cervical  vertebra  to  opposite  the  third 
dorsal,  where  it  divides  into  the  two  primitive  bronchi, 
right  and  left.  The  right  bronchus,  shorter,  more  hori- 
zontal, and  larger  than  the  left,  enters  the  right  lung 
opposite  the  fourth  dorsal  vertebra,  just  behind  the 
upper  border  of  the  second  costal  cartilage  of  the  right 


14 


PHYSICAL    DIAGNOSIS. 


side.  The  left  bronclius,  longer,  more  oblique,  and 
smaller  than  the  right,  passes  under  the  arch  of  the 
aorta  and  enters  the  left  lung  opposite  the  fifth  dorsal 
vertebra,  one  inch  lower  than  the  right.  Moreover,  the 
sej)tum  between  the  two  is  to  the  left  of  the  median 
line,  so  that  foreign  bodies  getting  into  the  trachea 
naturally  drop  into  the  right  bronchus  or  main  chaii- 


FiG.  4. — Division  of  the  Trachea  into  the  two  Primitive  Bronchi,  showing  the  Right 
Bronchus  much  larger  than  the  Left  and  given  off  higher  up.  (Schematic  Diagram.) 

nel.  It  is  reasonable  to  suppose,  therefore,  that  a  larger 
amount  or  volume  of  the  voice  is  conveyed  into  the 
right  lung,  especially  the  upper  part,  than  the  left,  and 
hence  more  vocal  fremitus  is  obtained  on  the  right  side. 
For  the  same  reason  more  fremitus  is  felt  posteriorly 
in  the  inter-scapular  region  of  the  right  side,  as  also 
slightly  more  in  the  riglit  sub-scapular  region  than  the 
left.     There  being  no  lung  tissue  over  the  superficial 


PALPATION.  15 

area  of  cardiac  dullness  in  the  left  mammary  region, 
and  over  the  liver,  in  front,  below  the  sixth  rib,  we  do 
not  exi)ect  to  find  ninch  fremitus  at  those  points  nsu- 
ally,  and  then  only  so  much  as  may  be  extended  there 
by  the  chest  walls.  The  normal  spleen  and  kidneys  do 
not  perceptibly  affect  the  fremitus.  Over  the  scapulae 
the  fremitus  is  interrupted  more  or  less  by  the  bone 
which  intervenes. 

The  amount  of  vocal  fremitus  differs  in  different 
healthy  individuals,  as  it  depends  for  its  production  on 
certain  important  factors.  These  may  be  embraced 
chiefly  under  two  heads:  (1)  the  character  of  the  voice 
and  (2)  the  conditions  of  the  chest  walls.  In  the  first 
place,  a  loud,  low-pitched,  harsh  voice  will,  other 
things  equal,  cause  more  vocal  fremitus  than  a  high- 
pitched  soft  voice.  For  this  reason  men  have  more 
fremitus  as  a  rule  than  women,  and  grown  people  more 
than  children.  The  bass  notes  of  the  large  pipes  of  an 
organ  produce  more  fremitus,  or  jarring,  than  the  high 
notes,  the  vibrations  of  the  former  being  more  power- 
ful and  longer.  And  in  like  manner  the  bass  viol 
produces  more  fremitus  or  jarring,  than  the  violin. 
Secondly,  the  chest  walls.  A  person  with  chest  walls 
covered  with  fat,  or  extra  development  of  muscle,  will, 
other  things  equal,  have  less  vocal  fremitus  than  one 
with  thin  chest  walls,  unencumbered  with  those  tissues, 
thin  chest  walls  requiring  less  force  to  be  thrown  into 
vibrations.  In  a  man  having  a  loud  bass  voice  and  a 
large  chest,  with  thin  chest  walls,  we  should  expect  to 
find  the  vocal  fremitus  well  marked,  but  more  on  his 
right  side,  for  reasons  already  given.  On  the  other 
hand,  we  may  not  be  able  to  detect  any  vocal  fremitus 


16  PHYSICAL    DIAGNOSIS. 

whatever  in  a  fat,  small-chested  woman  with  a  high- 
pitched  soft  voice.  It  is  of  the  greatest  importance  to 
know  that  in  health  the  vocal  fremitus,  usually  ob- 
tained, is  always  relatively  exaggerated  on  the  patient's 
right  side.  The  same  amount  of  fremitus  on  the  left 
side  would  probably  indicate  more  or  less  consolidation 
of  lung  tissue.  In  marked  deforaiities  of  the  chest, 
however,  such  as  those  caused  by  marked  spinal  curva- 
tures, exceptions  to  the  rule  are  usually  met  with  in 
all  the  methods  of  physical  examinations,  though  the 
lungs  be  perfectly  healthy.  This  is  what  might  be  ex- 
pected, but  it  is  well  to  bear  it  in  mind.  Finally,  and 
what  is  difficult  to  explain,  the  vocal  fremitus  appears 
to  be  very  slightly  increased  when  the  patient  is  in  the 
recumbent  iDosition,  a  fact  of  very  little  practical  im- 
portance, as  it  is  not  usually  noticeable. 

III.  Percussion. 

Percussion  is  the  act  of  striking  the  patient  one  or 
more  blows,  to  obtain  accurate  information  regarding 
the  underlying  parts,  and  is  the  third  step  in  the  regular 
order  of  the  physical  examination  of  the  chest.  It  should 
be  performed  gently  so  as  not  to  cause  pain  to  the 
patient.  Although  the  history  of  inspection  and 
palpation  appears  to  be  nowhere  stated,  it  is  well 
known  that  Auenbrt^ggeu  was  the  author  of  per- 
cussion. He  was  born  in  Gratz,  Styria,  in  1722,  and 
practiced  medicine  in  Vienna,  where  he  died  in  1809. 
He  discovered  the  value  of  percussion  while  engaged 
in  the  study  of  a  case  of  empyema.  He,  however, 
made  use  of  immediate  percussion  only,  and  pub- 
lished his  views   on   that   subject  in   1761.     But   it 


PEKCU8SION. 


17 


was  not  until  Piorry  of  Paris  invented  the  pleximeter 
in  1828  that  mediate  percussion  was  brought  into  gen- 
eral nse.  Piorry  also  drew  attention  to  the  increiised 
sense  of  resistance  which  accomi^anies  the  dull  sound 
elicited  by  percussing  solidified  lung  tissue,  and  lience 
one  of  the  advantages  of  palpatory  percussion,  with 
the  finger  as  a  pleximeter,  over  other  methods.  The 
percussion  hammer  was  invented  by  Wintricii  in  1841, 
and  when  employing  this  instrument,  instead  of  the 


Fig.  5.— Percussion  Hammers  and  Pleximeters. 

fingers,  it  is  necessary  frequently  to  use  a  pleximeter 
made  of  ivory  or  other  material,  which  may  be  flat  or 
otherwise.  A  solid  piece  of  ivory  about  two  inches 
long,  a  little  larger  than  an  ordinary  lead  pencil,  and 
shaped  somewhat  like  an  hour  glass,  is  useful  some- 
times in  percussing  just  above  and  below  the  clavicles 
in  cases  of  marked  depression  in  those  regions,  and  be- 
tween ribs,  in  some  cases  when  it  would  be  difficult  to 
apply  the  finger,  or  other  pleximeter.  To  perform  pal- 
patory percussion,  a  finger  of  the  left  hand  is  placed  as 
a  pleximeter  firmly  against  the  chest  walls  and  hori- 


18  PHYSICAL    DIAGNOSIS. 

zontally  Ibetween  ribs,  rather  than  vertically.  Then 
with  one  or  more  fingers  of  the  right  hand  (in  right- 
handed  persons)  curved  so  as  to  bring  their  tips  in  con- 
tact with  the  pleximeter,  and  moving  the  wrist  joint 
only,  three  to  five,  short,  sharp  blows,  are  rapidly  de- 
livered, which  j)rodnce  a  certain  sound.  The  pleximeter 
should  be  applied  alike  on  both  sides  of  the  chest  and 
the  blows  should  be  delivered  with  equal  force.  These 
rules  are  equally  applicable  when  the  percussion  ham- 
mer and  ivory  pleximeter  are  used.  The  percus- 
sion sound  difl'ers  for  different  parts  of  the  healthy 
chest,  and  is  composed  of  four  elements  or  properties, 
(1)  quality  or  timbre;  (2)  pitch;  (3)  duration  or  length, 
and  (4)  intensity  or  amount.  Of  these  properties  by 
far  the  most  important  is  quality. 

Quality  enables  us  to  tell  one  kind  of  a  sound  from 
another  regardless  of  all  other  proj^erties.  AYe  thus 
distinguish  the  sound  of  a  drum  from  the  blowing  of  a 
horn  and  these  two  from  piano  music.  It  is  not  by 
the  pitch,  intensity  or  duration,  that  we  recognize  the 
sound  of  the  drum,  but  by  the  quality  of  the  sound. 
And  so  for  all  other  musical  instruments.  The  drum 
may  be  small  and  give  a  high-xiitched  sound.  Or  it 
may  be  large  and  give  a  low-pitched  sound.  Or  the 
jDitch  may  vary  with  tightening  or  loosening  the  head 
of  the  same  drum.  While  the  pitch  maj^  vary  infinitely, 
the  quality  remains  the  same. 

In  percussing  over  healthy  vesicular  lung  tissue  we 
know  that  the  sound  elicited  is  the  normal  vesicular, 
or  i)ulmonary  resonance,  simply  by  the  quality  of  the 
sound  produced.  The  ,  pitch  will  vary  in  different 
healthy  people.    A  person  with  a  large  chest  will  give 


PERCUSSION,  19 

a  lower  pitched  note  j)erliai)s  than  one  with  a  small 
chest,  and  of  two  chests  of  the  same  size,  that  one  will 
give  a  higher  note  the  walls  of  which  are  more  tense 
or  thick  than  the  other.  Yet  the  quality  may  be  the 
same  for  all.  In  percussing  over  the  liver,  deltoid 
muscle,  or  any  solid  substance,  the  quality  of  the  note 
is  dull ;  over  fluids  inclosed  in  thin  walls  it  is  flat ;  and 
over  a  cavity  with  tense  walls  and  containing  air  it 
may  be  tympanitic.  If  it  be  a  large  cavity,  the  pitch 
will  be  low,  and  if  a  small  one,  other  things  equal,  it 
will  be  high,  relatively,  yet  it  will  be  tympanitic  in 
both  cases.  It  is  the  quality  of  the  percussion  note, 
then,  that  helps  us  to  distinguish  the  healthy  from  the 
pathological  condition,  and  one  pathological  condition 
from  another. 

Pitcli  as  an  attribute  of  chest  sounds  was  first 
brought  forward  by  Dr.  Walter  H.  Walshe,  of  London, 
about  1850.  It  is  not  possible  for  all  to  distinguish 
slight  differences  in  pitch,  as  it  is  a  natural  gift,  and 
belongs  to  those  who  have,  what  is  called,  an  ear  for 
music.  Even  then  it  requires  cultivation  and  practice. 
On  the  other  hand,  every  one  can  recognize  one  quality 
of  sound  from  another.  Pitch  is  often  of  use  in  dis- 
tinguishing different  degrees  of  the  same  class.  Thus  a 
high-pitched  tympanitic  percussion  note  gives  the  idea 
of  a  smaller  cavity,  with  tenser  walls,  than  low-pitched 
tjrmpanicity,  although  the  quality  in  both  cases  would 
be  the  same.  A  large  area  of  solidification  would  yield 
a  higher  pitched  percussion  note  than  a  small  one, 
though  the  quality  in  each  case  would  be  dull.  There 
are,  however,  different  degrees  of  dullness,  and  the  more 
marked  the  quality  of  dullness  is,  the  higher  will  be 


20  PHYSICAL    DIAGNOSIS. 

the  pitch.  Where  the  dullness  is  very  slight  the  pitch 
is  of  great  importance,  otherwise  it  is  not. 

Ordinary  respiration  does  not  affect  the  percussion 
note,  since  we  obtain  the  average  quality  of  the  sound 
during  percussion.  If,  however,  the  patient  be  directed 
to  take  a  deep  inspiration  and  hold  the  breath,  the 
note  may  be  a  little  different  then  from  one  made  at 
the  end  of  a  full  expiration.  In  the  foiTuer  case  the 
resonance  is  exaggerated,  but  the  j^itch  varies  for  dif- 
ferent cases,  sometimes  higher  and  sometimes  lower 
than  at  the  end  of  a  full  expiration,  according  to  the 
tension  of  the  chest  walls  and  the  volume  of  air  inhaled. 
A  chest  with  little  expansive  power  may  be  made  very 
tense  on  forced  inspiration  without  increasing  the  vol- 
ume of  air  in  proportion.  Here  the  j)itch  would  be 
higher  at  the  end  of  inspiration.  If  volume  exceeded 
tension  it  would  be  lower.  It  is  not  surprising,  there- 
fore, to  find  even  eminent  authors  differing  on  this 
rather  unimportant  point. 

Duration^  or  length,  as  an  element  or  property  of 
sound,  varies  with  the  pitch.  The  higher  the  pitch  the 
shorter  the  duration  or  length,  and  the  lower  the  pitch 
the  longer  \\ill  be  the  duration. 

Intensity,  or  amount,  as  already  stated,  is  used  in 
two  senses.  In  percussion  the  intensity  signifies  the 
amount  in  the  sense  of  amplitude  or  volume.  The 
lower  the  pitch,  therefore,  the  longer  the  duration  and 
the  greater  the  intensity,  or  volume,  of  the  x)ercussion 
note.  ^Normal  percussion  resonance  therefore  is  lower 
in  pitch,  longer  in  duration,  and  of  greater  intensity 
(volume)  than  dullness  which  is  higher  in  pitch,  shorter 
in  duration  and  of  less  intensity  (volume).     A  large 


PERCUSSION.  21 

cavity  giving  low-pitched  tympanicity  emits  a  more 
intense  percussion  note  than  a  small  one  giving  high- 
pitched  tympanicity.  All  these  elements  or  properties 
of  sound  are  important,  but  quality,  as  already  stated, 
is  first,  and  iiitch  second,  the  duration  and  intensity 
being  secondary  to  pitch. 

Let  us  now  examine  the  different  percussion  sounds 
obtained  in  percussing  different  regions  of  the  healthy 
chest ;  marked  deformities  being  excex)ted,  as  already 
stated,  when  speaking  of  palpation.  Great  care  should 
be  observed  in  symmetrically  arranging  the  patient  so 
as  to  be  able  to  compare  one  side  with  the  other  under 
the  same  conditions.  If  we  percuss  in  the  left  sub- 
clavicular (infra-clavicular)  region  a  certain  sound  is 
obtained  termed  the  normal  vesicular  resonance,  or 
the  normal  j^ulmonary  resonance.  The  quality  is  ves- 
icular, or  pulmonary,  due  to  the  presence  of  normal 
vesicular,  or  pulmonary  tissue.  The  pitch  is  some- 
what low,  the  duration  and  intensity  (volume)  being 
in  proportion.  In  the  right  sub-clavicular  (infra- 
clavicular) region  we  obtain  a  note  very  slightly  duller 
in  quality,  somewhat  higher  in  pitch,  shorter  in  dura- 
tion, and  of  less  intensity  (volume).  This  fact  is  of  the 
utmost  importance,  since  slight  dullness  on  percussion 
is  one  of  the  earliest  signs  of  incipient  phthisis,  due  to 
incomplete  consolidation.  Three  reasons  are  given  for 
this  difference.  (1)  The  right  pectoral  muscles  being 
more  developed  and  thicker  in  right-handed  i)ersons 
would  naturally  cause  the  note  to  be  slightly  duller  on 
the  right  side  than  the  left.  Should  the  patient  be 
left  handed  the  note  may  be  slightly  duller  on  the  left 
side  but  not  always.     We  then  look  for  some  other 


22  PHYSICAL    DIAGNOSIS. 

reason.  (2)  The  right  lobe  of  the  liver  acting  as  a  solid 
foundation  for  the  right  lung  is  regarded  by  some  as 
the  cause  for  a  higher  percussion  note  on  the  right  side 
than  the  left,  the  left  lung  being  in  relation  with  the 
large  end  of  the  stomach.  The  heart  being  situated 
chiefly  on  the  left  side,  however,  this  theory  is  disputed 
and  even  rejected  by  some.  (3)  Lastly  the  difference  is 
said  by  some  to  be  due  to  the  difference  in  the  anatom- 
ical arrangement  of  the  bronchial  tubes.  The  right 
bronchial  tube  being  larger,  and  situated  higher  up,  than 
the  left,  gives  us  broncho-pulmonary,  or  broncho-vesicu- 
lar tissue,  to  deal  with  in  which  the  bronchial  element 
is  more  marked  than  in  the  same  region  on  the  left 
side.  And  it  is  not  improbable  that  bronchial  tubes 
with  their  muscular  coats  and  more  or  less  connective 
tissue,  occupying  space  that  is  taken  up  in  the  left 
side  by  air  cells,  would  give  a  slightly  duller  note. 
Flint,  however,  states  that  they  probably  raise  the 
pitch  by  imparting  to  the  note  a  slightly  tympanitic 
quality  of  high  pitch. 

The  resonance  obtained  by  immediate  percussion  on 
the  clavicles  is  not  always  indicative  of  the  true  condi- 
tion of  the  lungs  underneath,  and  hence  is  not  to  be  de- 
pended on.  The  properties  of  the  note  will  vary  with 
the  length  and  shape  of  the  bone.  For  these  reasons  a 
slightly  duller  note  is  often  obtained  over  the  left  clavi- 
cle than  the  right,  in  perfectly  healthy  chests. 

The  mammary  regions  being  covered  over  with  more 
adipose  tissue  than  those  above  or  below  in  connection 
with  the  mammary  glands  which  are  also  more  or  less 
developed,  the  note  in  these  regions  would  naturally 
be  less  resonant  than  in  tliose  above.     Moreover  in  the 


PERCussioisr.  23 

left  mammary  region  we  have  within  the  line  of  the 
left  nipple  the  deep  and  siqierficial  areas  of  cardiac 
dullness,  the  former  extending  into  the  right  mammary 
region  about  half  an  inch  to  the  right  of  the  sternum. 
Along  the  lower  margin  of  tne  right  mammary  region 
we  find  the  line  of  deep  hepatic  dullness. 

The  right  hypochondriac  (infra-mammary)  region 
being  occupied  by  the  right  lobe  of  the  liver  we  obtain 
here  marked  hejpatic  dullness.  It  should  not  be  called 
flatness,  however,  as  that  quality  is  obtained  by  per- 
cussing over  fluids  contained  in  thin  walls.  In  the 
upper  part  of  the  left  hypochondriac  region  and  at  its 
outer  boundary  we  may  obtain  some  dullness  from  the 
left  lobe  of  the  liver  and  anterior  border  of  the  spleen, 
but  owing  to  the  larger  end  of  the  stomach  the  percus- 
sion note,  especially  under  forcible  percussion,  is  often 
tympanitic.  Over  the  sternum  dullness  by  means  of 
gentle  percussion  is  usually  obtained  on  account  of  the 
bone.  But  forcible  percussion  over  the  trachea  and 
bronchi  down  to  the  line  of  the  upper  border  of  the 
third  ribs  will  give  tympanicity  or  rather  bandbox 
resonance.  Below  the  third  ribs  the  heart  and  liver 
cause  dullness. 

In  percussing  the  posterior  regions  of  the  chest  the 
patient  should  assume  the  same  position  as  for  palpa- 
tion, so  as  to  get  the  scapulae  as  much  out  of  the  way 
as  possible  and  render  the  tissues  tense.  In  the  supra- 
scapular regions  forcible  percussion  elicits  pulmonary 
resonance  to  a  certain  extent,  but  it  is  muffled  by  the 
thick  covering  of  over-lying  tissues.  This  is  even  more 
the  case  in  the  inter-scapular  regions.  Over  the  scapu- 
lar regions  the  bone  interferes  with  the  resonance.     In 


24  PHYSICAL    DIAGNOSIS. 

the  sub-scapular  (infra-scapular)  regions,  however,  we 
get  pulmonary  resonance  down  to  the  lower  limit  of 
the  lungs,  which  is  the  tenth  rib  on  both  sides.  The 
note,  however,  is  slightly  duller  and  consequently 
higher  pitched  in  the  right  sub-scapular  region  than 
the  left,  both  on  gentle  and  forcible  percussion.  The 
right  muscles  of  the  back  being  usually  thicker  than 
the  left,  and  the  right  lobe  of  the  liver  affording  a  solid 
substance  against  which  we  percuss  on  the  right  side, 
fully  account  for  this  difference.  The  lungs  only  ex- 
tend down  to  the  tenth  ribs  on  the  vertebral  lines  (both 
sides  of  the  spinal  column),  so  that  below  those  ribs 
there  is  usually  marked  dullness.  In  ]percussing  the 
lateral  regions  the  patient  should  place  on  the  head  the 
hand  of  the  side  percussed.  In  the  axillary  regions  of 
both  sides  we  get  loud  pulmonary  resonance.  In  the 
sub-axillary  (infra-axillary)  region  of  the  right  side 
we  come  down  to  hepatic  dullness  on  the  axillary  line, 
between  the  seventh  and  eighth  ribs,  and  it  continues 
down  to  the  eleventh.  In  the  same  region  on  the  left 
side  there  is  some  dullness  on  percussion  over  the 
spleen  from  the  ninth  to  the  eleventh  ribs.  Forcible 
percussion  in  this  region,  however,  may  elicit  tympa- 
nicity  from  the  large  end  of  the  stomach. 

In  children  the  percussion  note  is  usually  more  reso- 
nant than  in  adults,  owing  to  their  thin  chest  walls. 
In  women,  for  the  same  reason  and  on  account  of  their 
superior  costal  respiration,  the  resonance  is  more 
marked  than  in  men,  especially  in  the  upper  part  of 
the  chest;  while  in  the  aged,  the  chest  walls  becoming 
more  and  more  rigid,  and  the  lungs  smaller  in  volume, 
less  resonance  is  to  be  expected  as  a  rule. 


AUSCULTATION. 


25 


IV.  Auscultation. 

Auscultation  is  the  act  of  listening,  and  may  be  done 
immediately  by  placing  the  ear  directly  against  the 
chest,  or  mediately  by  the  intervention  of  a  stetho- 
scope. In  the  former  case  a  thin  soft  towel,  or  other 
similar  material,  may  be  used  to  cover  up  the  chest. 


Fig.  6.— Stethoscopes. 
A.  Ford's  silent  circular  spring.    B.  Screw  for  regulating  ear-pressure. 

The  same  observations  regarding  the  position  of  the 
patient  in  palpating,  or  j)ercussing,  apply  here. 

Hippocrates,  460-375  B.C.,  was  the  first  to  make  use 
of  auscultation  as  a  procedure  in  physical  diagnosis, 
but  only  to  the  limited  extent  of  hearing  the  splashing 
of  fluid  by  succussion,  in  the  case  of  pneumohydro- 
thorax.  It  was  not  until  1816  that  Laennec,  of  the 
IS'ecker  Hospital,  in  Paris,  invented  the  stethoscope 


26  PHYSICAL    DIAGNOSIS 

and  Urst  gave  to  auscultation  the  value  which  it  now 
possesses.  In  1840  Dr.  Camman,  of  New  York  City, 
invented  the  binaural  stethoscope.  The  ear  pieces  of 
this  instrument  should  fit  jDroperly,  and  the  spring,  or 
elastic,  may  be  guarded  by  a  screw  so  as  to  regulate 
the  pressure  in  the  ears,  otherwise  injury  to  the  ears 
must  follow  sooner  or  later.  The  moderate  use  of  the 
stetliosco2:)e  for  locating  heart  murmurs  is  good,  but  in 
other  cases  the  ear  is  to  be  x^referred  when  possible. 

In  the  auscultation  of  the  healthy  chest  we  listen  for 
the  breath  sounds  and  the  voice  sounds ;  the  respira- 
tory murmur  and  the  pectorophony,  or  vocal  resonance 
as  heard  over  the  chest.  The  i:)atient  should  be  directed 
to  clear  the  throat  if  necessary  and  not  to  make  anj'' 
sux)erfluous  noise  in  breathing. 

Normal  Respiratory  Murirmr. — If  now  we  place 
the  ear  or  stethoscope  to  the  chest  while  the  patient 
breathes  with  a  moderate  amount  of  force,  we  hear  the 
normal  respiratory  murmur,  or  breath  sound,  which 
for  reasons  already  given  is  more  marked  in  women 
than  in  men,  esj)ecially  in  the  upper  part  of  the  chest. 

This  normal  respiratory  murmur  is  a  more  or  less 
composite  sound  in  which  the  larynx,  trachea,  bron- 
chial tubes,  air  vesicles,  and  perhaps  other  elements  ai-e 
concerned.  It  differs  for  different  regions  of  the  chest 
and  is  designated  according  to  the  predominating  qual- 
ity present.  In  the  left  sub-clavicular  region,  for  in- 
stance, we  have  the  type  of  the  normal  A'esicular  respii-a- 
tory  murmur,  the  vesicular  (rustling,  breezy)  quality 
predominating  on  account  of  the  presence  of  the  pul- 
monary vesicles  or  air-cells.  In  rhythm  the  length  of 
the  insi)iration   of   the  nonnal    vesicular  respiratory 


AUSCULTATIOISr.  27 

murmur  is  about  four  times  the  length  ojl  exj)iration 
and  continuous  with  the  latter.  Inspiration  is  vesicu- 
lar (breezy  or  rustling)  in  quality,  of  a  certain  pitch, 
which  may  be  regarded  as  somewhat  low,  and  of  a  cer- 
tain intensity,  which  varies  in  different  healthy  chests. 
The  expiration  when  present  is  always  continuous  with 
inspiration,  but  is  absent,  according  to  Flint,  in  about 
one-fourth  of  the  cases.  This  is  esp)ecially  true  with 
men,  particularly  on  the  left  side.  Expiration  is 
blowing  in  quality  and  lower  in  pitch  than  insi)ira- 
tion.  Guttmann  truthfully  states  that  this  resjDira- 
tory  murmur  may  be  imitated  by  properly  adjusting 
the  lips  (nearly  closing  them)  and  drawing  in  and  ex- 


Fig.  7. — Normal  Vesicular  vespiratory  murmur. 

pelling  air  through  them  on  the  proper  key  with  due 
regard  to  duration.  In  fact  any  respiratory  murmur 
may  be  imitated  in  the  same  way,  as  in  whispering  a 
tune.  The  reason  why  exi^iration  is  shorter  than  in- 
siDiration,  according  to  Walshe,  is  because  in  the  latter 
instance  fhe  air  current  is  directed  toward,  in  the 
former  from,  the  ear  of  the  auscultator.  Either  in- 
spiration or  expiration  or  both  may  be  wavy  in  x)er- 
fectly  healthy  chests.  We  find  it  in  the  hysterical 
and  nervous.  Palpitation  of  the  heart  may  cause  it, 
especially  on  the  left  side.  Even  wdien  interrupted, 
cog- wheeled,  or  jerky,  it  is  not  necessarily  associated 
with  incipient  phthisis. 

The  normal  respiratory  murmur  heard  in  the  right 
sub-clavicular  region  differs  somewhat  from  that  heard 


M 


28  PHYSICAL    DIAGIS^OSIS. 

in  the  left.  On  the  right  side  the  bronchus  imparts 
to  it  a  bronchial  element  not  heard  on  the  left.  In 
other  Avords  we  have  the  normal  vesiculo-bronchial 
respiratory  murmur  on  the  right  side,  a  fact  of  the 
utmost  inqDortance,  especially  when  taken  with  the 
other  physical  signs  in  this  region,  all  of  which  very 
closely  resemble  those  of  incipient  j)hthisis.  In  this 
vesiculo-bronchial  murmur  the  chief  characteristics  are 
that  expiration  is  prolonged,  raised  in  pitch,  and  some- 
what tubular  in  quality,  and  the  murmur  as  a  whole 
is  more  intense  (exaggerated)  than  it  is  on  the  left 
side.  Insi)iration  is  also  slightly  higher  in  pitch  and 
less  vesicular  in  quality  than  on  the  left  side. 

In  the  supra-sternal  region  by  placing  the  stetho- 
scoi)e  over  the  trachea  we  get  the  nornial  tracheal 
breathing,  and  in  the  inter-scajDular  region,  esj^ecially 
of  the  left  side,  as  the  left  primitive  bronchus  is  more 
deeply  situated  than  the  right,  we  obtain  the  normal 
bronchial  breathing  over  the  site  of  the  left  primitive 
bronchus.  In  this  both  inspiration  and  expiration  are 
tubular  in  quality.  The  bronchial  respiratory  murmur 
resembles  the  tracheal  but  is  less  intense.  Over  the 
larynx  we  have  the  normal  laryngeal  breathing.  Over 
the  liver  and  superficial  area  of  cardiac  dullness,  w^here 
no  lung  tissue  exists,  we  hear  no  respiratory  murmur, 
unless  it  may  be  transmitted  along  the  chest  walls. 
Over  the  scapuhe  the  murmur  is  weak  or  absent  on  ac- 
count of  the  intervening  bone.  The  normal  vesicular 
respiratory  murmur  besides  being  heard  in  the  left 
sub-clavicular  region  is  also  heard  in  both  axillary  re- 
gions and  the  sub-scapular  regions.  The  respiratory 
murmur  may  also  be  heard  in  the  supra-clavicular  and 


AUSCULTATION.  29 

supra- scapular  regions.  In  any  locality  it  may  become 
exaggerated,  supplementary,  or  hypervesicular  in  cer- 
tain cases  where  one  lung  or  portion  of  a  lung  is  doing 
extra  work  for  a  short  time.  In  children  before  the 
vesicular  element  of  the  lungs  has  become  fully  devel- 
oped and  also  owing  to  their  thin  chest  walls,  the  res- 
piratory murmur  is  termed  puerile.  It  is  less  vesicular 
and  more  intense  than  in  adult  life,  but  is  not  neces- 
sarily therefore  harsh.  In  old  age  the  murmur  be- 
comes less  intense  and  the  rhythm  changed,  inspira- 
tion being  shortened  and  expiration  j^rolonged. 

Normal  PectoroiDTiony  (chest  voice),  vocal  resonance, 
or  voice  sound  over  the  chest,  in  health  is  the  sound 
produced  by  the  patient's  voice  as  heard  through  the 
chest  walls.  It  is  a  distant,  diffused,  indistinct  sound, 
being  more  or  less  buzzing.  The  ear  or  stethoscope, 
preferably  the  ear,  should  be  applied  to  the  chest  and 
the  patient  directed  to  speak  out  the  words  one,  two, 
three,  repeating  them  as  often  as  necessary. 

N'ormal  pectorophony  (chest  voice)  or  vocal  reso- 
nance, differs  in  different  healthy  people  according  to 
the  character  of  the  voice  and  the  conditions  of  the 
chest  walls,  and  for  different  localities,  just  exactly 
like  the  normal  vocal  fremitus.  What  has  been  already 
stated  about  the  latter,  therefore,  equally  applies  to  the 
former.  It  is  normally  exaggerated  (slightly  increased) 
in  the  patient's  right  sub-clavicular  region  and  else- 
where, like  the  fremitus. 


450  PHYSICAL    DIAGNOSIS. 

SUMMARY   OF   THE   PHYSICAL   SIGNS   OF   THE 
HEALTHY  CHEST. 

1.  Inspection.^- A  perfectly  symmetrical  chest  is  rare. 
The  shoulders  may  not  be  on  the  same  level,  and  there 
may  be  slight  lateral  curvature  of  the  spine.  The  apex- 
l)eat  of  the  heart  may  or  may  not  be  visible,  according, 
chiefly,  to  the  thickness  of  the  chest  walls.  There  is 
equal  and  general  exj^ansion  of  the  chest  walls  on  both 
sides  during  insiDiration.  Superior  costal  respiration 
is  noticeable  in  women,  abdominal  respiration  in  men. 
The  scapuhe  move  evenly,  except,  for  instance,  in  nerv- 
ous people. 

2.  Palpation. — The  normal  vocal  fremitus  varies  in 
different  people,  depending  on  the  character  of  the 
voice  and  the  conditions  of  the  chest  walls.  It  is,  how- 
ever, more  perceptil^le  all  over  the  i)atient's  right  side 
than  the  left  and  is  especially  exaggerated  in  the  right 
sub-clavicular,  inter-scapular,  and  sub-scapular  regions, 
since  the  right  bronchial  tube,  larger  than  the  left, 
conducts  a  larger  volume  of  voice  to  the  right  side. 
The  apex-beat  of  the  heart  is  usually,  but  not  always, 
felt. 

3.  Percussion. — We  obtain  normal  pulmonary  res- 
onance in  the  left  sub-clavicular  region,  both  axillary 
regions,  and  the  left  sub-scapular  region.  In  the  right 
sub-clavicular  and  sub-scajDular  regions  the  note  is 
slightly  duller  than  in  those  regions  of  the  left  side, 
owing  chiefly  to  the  difference  in  the  thickness  of  the 
muscles.  Over  the  liver  and  superficial  area  of  car- 
diac dullness  we  o})tain  marked  dulhiess.  Over  the 
spleen  in  the  left  sub-axillary  region,  from  the  ninth  to 


HEALTHY    CHEST — SUMMARY.  31 

the  eleventh  ribs  on  the  axillary  line,  there  is  slight 
dullness  mingled  not  infrequently  with  ventral  tyiu- 
panicity.  In  the  scax)u]ar  and  inter-scapular  regions 
the  resonance  is  interfered  with  by  the  intervening 
bone  and  muscles. 

4.  Auscultation. —  In  the  left  sub-clavicular,  both 
axillary  and  sub-scapular  regions,  we  hear  the  normal 
vesicular  respiratory  murmur.  In  the  right  sub-cla- 
vicular region  we  hear  the  normal  vesiculo-bronchial 
respiratory  murmur  owing  to  proximity  to  the  right 
primitive  bronchus.  Over  the  larynx,  trachea  and 
bronchi  we  hear  the  respiratory  murmur  characteristic 
of  those  organs.  Over  the  liver  and  superficial  area  of 
cardiac  dullness  the  respiratory  murmur  may  be  en- 
tirely absent  unless  transmitted  there  by  the  chest 
walls.  The  normal  pectorophony  (vocal  resonance  over 
the  chest)  is  exaggerated  in  the  right  sub-clavicular 
region  and  is  also  more  intense  in  the  right  inter-scap- 
ular and  sub-scajpular  regions  than  the  left  for  the  same 
reason  that  the  fremitus  is. 

From  the  foregoing  observations  we  deduce  the 
following  differential  summary  of  the  physical  signs 
as  obtained  in  the  right  and  left  sub-clavicular  re- 
gions in  the  healthy  chest:  (1)  Inspection  is  chiefly 
negative.  (2)  Palpation  gives  exaggerated  vocal  frem- 
itus on  the  patient's  right  side.  (3)  Slight  dullness 
on  percussion  in  the  patient's  right  side,  the  pitch 
being  slightly  raised.  (4)  Upon  auscultation  we  find 
vesiculo-bronchial  respiratory  murmur  and  exagger- 
ated pectorophony  (vocal  resonance)  on  the  patient's 
right  side.  In  other  words,  we  have  in  the  right  sub- 
clavicular region  of  the  healthy  chest  all  the  signs  of 


\ 


32  PHYSICAL    DIAGNOSIS. 

incomplete  consolidation  of  lung  tissue  as  seen  in  the 
early  stage  of  phthisis,  except  some  adventitious  sound, 
such  as  crepitant,  or  sub-crepitant  rales,  or  the  mucous 
or  intra-pleural  click.  "  Without  a  practical  knowledge 
of  these  points  of  disparity,"  says  Flint,  "  error  in  di- 
agnosis can  hardly  be  avoided."  In  cases  of  doubt  the 
siDuta  should  be  examined  by  an  expert  for  the  tuber- 
cle bacillus,  though  it  is  not  always  found  at  this  early 
Gtage. 

OTHER  MEANS  EMPLOYED   IX  PHYSICAL  DIAGNOSIS. 

Mensuration,  or  measurement,  may  be  of  use  in 
comparing  the  two  sides  of  the  chest  in  repose,  or  dur- 
ing inspiration  and  expiration,  or  to  ascertain  the  total 
amount  of  expansibility  of  the  chest.  Even  in  these 
cases  inspection  is  usually  sufficient.  Moreover,  a  dis- 
eased jjerson  can  sometimes,  by  practice,  expand  the 
chest  walls  more  than  a  healthy  one  who  has  not  prac- 
ticed. It  is  of  use  sometimes  in  ascertaining  the  size 
of  the  chest  in  proportion  to  the  height.  Thus  a  man 
5  feet  6  inches  high  should  measure  around  the  chest, 
on  a  level  \Adth  the  sixth  costo-sternal  articulations,  37^ 
inches ;  5  feet  8  inches  high,  38^  inches ;  5  feet  10  inches 
high,  39|^  inches;  6  feet  high,  41  inches,  and  so  on. 
Tliree  inches  is  good  expansion  of  a  healthy  chest  on 
full  inspiration,  although  the  healthiest  i^erson  may 
not  be  able  to  expand  the  chest  oxer  two  inches  Avith- 
out  practice,  while  it  may  be  i)ossible  with  practice  to 
expand  it  six  inches.  Various  instruments,  such  as  the 
stethometer,  spirometer,  and  cyrtometer,  have  been 
used  for  mensuration.  Tlie  ordinary  tape-line,  however, 
is  good  enough  for  j^ractical  purposes. 


VAEIOUS   METHODS.  33 

Auscultatory-Percussion,  was  invented  by  Dr.  Cam- 
man,  of  ]N'ew  York,  about  1840.  It  combines  ausculta- 
tion by  means  of  the  stethoscope  with  percussion. 
While  the  stethoscope  is  firmly  pressed  over  the  heart, 
for  instance,  percuss  gently  at  the  same  time.  As  soon 
as  the  percussion  reaches  the  border  of  the  heart  the 
quality  and  pitch  of  the  note  is  changed  at  once.  It 
is  a  much  more  delicate  test  than  the  ordinary  method 
of  percussion,  and  is  especially  useful  in  diagnosing 
thoracic  aneurism.  It  may  also  be  used  for  accurately 
determining  the  boundaries  of  the  heart,  liver,  and 
other  organs  of  the  body.  Unless  performed  correctly 
and  carefully,  however,  it  is  misleading.  A  pleximeter, 
small  enough  to  be  pressed  down  between  the  ribs, 
should  be  used,  otherwise  we  always  obtain  the  dull 
percussion  resonance  of  the  superficial  adipose,  or  other 
tissue,  instead  of  that  of  the  underlying  organs. 

Sicccussion,  invented  by  Hipxoocrates,  460-375  B.C., 
consists  in  shaking  the  patient  while  the  ear  is  at  the 
same  time  applied  to  the  patient's  chest.  By  this 
means  the  splashing  sound  of  fluid  characteristic  of 
pneumo-hydrothorax  is  detected,  as  will  be  fully  de- 
scribed. 

Paracentesis  Thoracis,  or  Tlioracentesis^  in  cases 
of  extensive  pleuritic  effusions,  whether  of  serum  or 
pus,  was  first  brought  before  the  profession  in  a  prac- 
tical manner  by  Trousseau,  of  Paris,  about  1835.  After 
his  death  it  fell  into  disuse,  but  was  revived  in  1852  by 
Dr.  Bowditch,  of  Boston,  Massachusetts,  who  clearly 
pointed  out  the  indications  for  the  operation,  as  will  be 
mentioned  when  speaking  of  that  subject.  More  re- 
cently by  means  of  the  hypodermic  syringe  the  exist- 
3 


34  PHYSICAL    DIAGNOSIS. 

ence  and  character  of  pleuritic  effusions  can  be  estab- 
lished with  certainty. 

Other  less  important  procedures  are  autophonia,  the 
method  by  musical  vibrations,  and  phonometry. 

Autophonia  was  first  brought  into  notice  by  the 
late  M.  Hourmann,  who  "  connected  peculiarities  in  the 
resonance  of  the  observer's  own  voice  (as  he  speaks 
with  the  ear  applied  to  the  chest  directly,  or  by  the 
intervention  of  the  stethoscope)  with  certain  definite 
conditions  of  density  of  the  parts  beneath." 

The  method  by  musical  vibrations  originated  with 
Drs,  Stone  and  Grabham  (London  Lancet,  vol.  i.,  1867, 
p.  114),  and  consists  in  "  communicating  a  musical  im- 
pulse to  the  air  in  the  bronchial  i^assages  by  forcibly 
inspiring  through  a  tube  or  pitch-i)ipe  containing  a 
free  reed.  The  note  emitted  is  directly  conveyed  to 
the  i)arts  under  observation." 

Phonometry  is  a  metliod  described  by  Baas.  It 
consists  in  "  i^lacing  a  tuning  fork  on  the  surface  of 
the  chest  or  abdomen,  and  determining  by  the  inten- 
sity or  feebleness  of  the  tone  it  gives,  the  condition 
of  the  subjacent  organs."  The  best  instrument  for 
this  purpose  is  Blake's  tuning  fork  with  a  small 
spring  hammer  attached.  The  usual  method  of  per- 
cussion, however,  is  much  to  be  preferred. 

Having  become  thoroughly  and  practically  ac- 
quainted with  the  physical  signs  obtained  by  examin- 
ing the  healthy  chest,  the  student  is  now  prepared  to 
consider  the  physical  signs  of  various  diseases. 


CHAPTEE  II. 

BRONCHITIS. 

Diseases  in  which  the  breath  and  voice  sounds  are  refracted 
(broken  up,  diffused)  within  the  lungs  as  much  as,  or  more 
than  in  healtli,  with  consequent  normal  or  diminished  vocal 
fremitus,  respiratory  murmur,  and  pectorophony. — Obstruc- 
tion in  the  bronchial  tubes  to  the  convection  of  sound,  with 
consequent  diminution  or  suppression  of  the  latter. — Ad- 
ventitious sounds. 

Bronchitis  is  the  inflammation  of  the  mucons  mem- 
brane lining  the  larger  or  medium-sized  bronchial  tubes, 
but  when  the  smaller  or  ultimate  bronchial  tubes  be- 
come the  seat  of  the  disease  it  is  called  capillary  bron- 
chitis. In  neither  case  are  the  air  cells  affected  unless 
as  a  complication.  As  independent  primary  diseases 
they  are  general  or  bilateral,  local  bronchitis  being 
usually  caused  by  and  secondary  to  some  other  disease, 
tubercle,  aneurism,  or  neoplastic  growth  for  instance, 
or  surgical  injury. 

The  physical  signs  of  bronchitis,  apart  from  compli- 
cations, are  as  follows : 

Inspection. — This  yields  chiefly  a  negative  result. 
Usually  there  is  no  perceptible  difference  from  health 
in  the  size  and  shape  of  the  chest  and  character  of  the 
respiratory  movements.  Especially  is  there  no  differ- 
ence in  the  respiratory  movements  of  the  two  sides, 
when  compared  with  one  another,  but  both  expand 
alike. 


36  PHYSICAL    DIAGNOSIS. 

Palpation. — This  also  gives  negative  results  gener- 
ally. The  vocal  fremitus  is  usually  normal,  or  it  may 
be  slightly  diminished  if  the  bronchial  tubes  are  much 
obstructed  by  mucus,  so  that  the  voice  sound  is  not 
conveyed  by  them  as  freely  as  in  health.  In  rare  cases 
a  large  tube,  the  left  primitive  bronchus,  for  instance, 
the  right  being  usually  too  large,  or  a  large  branch  of 
either,  becomes  stopped  up  by  a  plug  of  viscid  mucus, 
with  diminution  or  even  absence  of  the  vocal  fremitus 
over  the  corresponding  area.  Coughing  may  remove 
the  plug  and  then  the  fremitus  immediately  returns. 
In  case  of  coarse  mucous  rales,  especially  with  thin 
chest  walls,  rhonchal  fremitus  may  be  present. 

Percussion. — This  also  yields  negative  results,  the 
air  cells  in  uncomplicated  bronchitis  being  unaffected 
and  full  of  air.  Sometimes  the  resonance  may  even  be 
exaggerated  owing  to  the  abnormal  distention  of  the 
air  cells  with  air.  This,  however,  will  be  explained 
when  speaking  of  emphysema.  In  old  cases  of  bron- 
chitis where  the  inllammation  has  extended  so  as  to 
give  rise  to  peri-bronchial  thickening  or  interstitial  in- 
flammation, more  or  less  dullness  on  percussion  will 
result  from  those  complications. 

Auscultation. — The  respiratory  murmur  may  be 
weakened  if  the  tubes  are  much  obstructed  with  mucus, 
or,  if  a  large  tube  be  plugged  up  as  already  described, 
the  respiratory  murmur  may  be  entirely  absent  for  the 
corresponding  area.  Upon  coughing  and  removing  the 
obstruction  the  respiratory  murmur  immediately  re- 
turns. When  heard,  however,  its  quality  is  the  same 
as  in  health  as  a  rule.  It  may,  however,  be  a  little 
harsh  (rough)  if  the  mucous  membrane  of  the  larger 


BRONCHITIS— KALES.  37 

bronchi  is  mncli  roughened  where  the  tidal  air  rubs 
against  it  instead  of  gliding  smoothly  and  without 
much  friction,  as  in  health.  Expiration  will  be  more 
or  less  prolonged  in  proportion  to  the  amount  of  ob- 
struction in  the  tubes,  the  force  of  ordinary  expiration 
being  weaker  than  that  of  inspiration.  PectoroiDhony 
(vocal  resonance  over  the  chest)  is  usually  normal,  but 
may  be  slightly  diminished  like  the  vocal  fremitus. 
Relatively  the  vocal  fremitus  and  pectorophony  are 
the  same  as  in  health  in  comparing  one  side  with  the 
other. 

Rales  (rattles)  are  usually  heard  in  bronchitis  and 
belong  to  the  adventitious  or  foreign  sounds.  These 
never  exist  nntil  produced  by  disease.  Adventitious 
sounds  are  abnormal  from  beginning  and  are  not  modi- 
fied normal  sounds.  Their  presence,  therefore,  always 
indicates  some  abnormal  condition.  (See  Summary  of 
Adventitious  Sounds,  ChaiD.  Y.)  The  rales  heard  in 
bronchitis  may  be  dry  or  moist.  There  are  two  varieties 
of  dry  rales,  the  sonorous  and  sibilant.  Sonorous  rales 
are  loud,  low-pitched,  dry  rales  made  in  the  larger  bron- 
chial tubes.  The  sibilant  are  high-pitched,  whistling 
rales  made  in  the  smaller  tubes,  or  in  larger  tubes  if 
the  constriction  be  sufficient.  They  are  heard  in  the 
early  or  dry  stage  of  bronchitis  and  asthma,  and  are 
du3  to  irregularity  in  the  calibre  of  the  tubes  from 
spasmodic  constriction  of  the  muscular  coats,  or  tume- 
faction of  the  lining  mucous  membrane.  Sometimes 
they  are  also  caused,  undoubtedly,  by  the  vibration  of 
viscid  mucus,  and  hence  are  changed  with  coughing. 

Moist  bronchial  rales  are  divided  into  three  varieties. 
Those  made  in  the  larger  bronchial  tubes  are  large  bub- 


38 


PHYSICAL    DIAGNOSIS. 


bling  rales  heard  both  on  inspiration  and  expiration, 
and  are  called  mucous  rales. 

Those  made  in  the  medium-sized  bronchial  tubes  are 
called  sub-mucous  rales.  They  are  also  bubbling  rales 
heard  both  on  inspiration  and  expiration,  but  are  liner 
and  higher  pitched  than  the  mucous  rales.  Lastly  we 
have  the  sub-crepitant  rales  made  in  the  liner  bronchi. 


Fig.  8.— Bronchial  Rales,  mr,  Mucous  rales;  smr,  sub-mucous  rales;  so;  sub-crep- 
itant rales;  cr,  crepitant  rales;  t,  tumefaction;  s,  spasmodic  stricture  of  bronchial 
tube. 

These  are  fine  moist  rales,  heard  chieHy  on  inspiration, 
though  occasionally  they  are  heard  on  expiration  also. 
All  of  these  rales  may  be  present  together,  or  only  one 
or  more  varieties.  They  may  be  abundant,  scant,  or 
even  absent  at  times.  In  the  latter  case,  coughing  may 
develop  them.  When  present  they  usually  change 
with  or  even  without  coughing,  are  more  or  less  irregu- 
lar in  size,  and  are  attended  with  more  or  less  ex- 
pectoration.    In  this  way  tliey  differ  from  intra-i)leural 


BRONCHITIS.  39 

moist  rales,  which  are  usually  local,  do  not  change  with 
couching,  are  uniforai  and  superficial,  and  attended 
with  little  or  no  expectoration. 

The  patient  should  be  directed  to  clear  the  throat  to 
avoid  laryngeal  and  tracheal  rales,  the  sound  of  which 
may  be  conveyed  to  the  ear  through  the  bronchial 
tubes  and  air  cells. 

Other  adventitious  sounds  are  the  crepitant  rales 
made  in  the  air  cells,  intra-pleural  rales,  mucous  and 
intra-pleural  click,  gurgles,  metallic  (amphoric)  tinkle, 
friction  sounds,  splashing  sounds,  and  certain  crackling 
and  crumpling  sounds  called  indeterminate  rales,  to  be 
.described  each  in  its  proper  x)lace.  (See  also  Summary 
of  Adventitious  Sounds,  ^.  159,  Chap.  V.) 

Capillary  Broncliitis  is  the  inflammation  of  the 
mucous  membrane  lining  the  smallest  or  ultimate  bron- 
chial tubes,  the  air  cells  still  remaining  unaffected  ex- 
cept as  a  complication.  It  occurs  most  frequently  in 
children.  It  is  also  seen  among  the  aged  and  others 
having  enfeebled  heart's  action,  and  hence  may  occur 
in  the  course  of  long-continued  diseases  of  a  typhoid 
character.  ' 

The  physical  signs  are,  in  general,  similar  to  those  of 
ordinary  bronchitis. 

Ins])ection^  however,  may  reveal  increased  frequency 
of  respiratory  movements  and  sometimes  more  or  less 
cyanosis,  especially  about  the  cheeks,  ears,  tip  of  the 
nose,  lips,  and  fingers.  (See  Atelectasis  and  Lobular 
Pneumonia.) 

Palpation  generally  yields  negative  results,  or  the 
fremitus  may  be  diminished  or  even  absent  from  ob- 
struction of  the  tubes,  as  already  stated. 


40  PHYSICAL    DIAGNOSIS. 

Percussion. — The  percussion  note  may  be  normal,  or 
it  may  be,  and  frequently  is,  exaggerated  from  tem- 
porary over-distention  of  the  air  cells.  This  is  due  to 
the  fact  that  forced  expiratory  efforts  empty  chiefly 
the  larger  bronchi  but  have  very  little  influence  over 
the  air  cells.  Hence,  so  far  as  the  air  cells  are  con- 
cerned, inspiration  is  a  more  forcible  act  than  expira- 
tion. The  air  passes  by  the  mucous  obstruction  into 
the  air  cells  more  easily  than  it  gets  out,  and  so  accu- 
mulates in  the  air  cells  and  distends  them.  On  the 
other  hand,  if  the  patient  is  very  feeble,  as  is  not  infre- 
quently the  case  with  sick  children  or  the  aged,  or 
those  suffering  with  typhoid  fever,  the  air  cells  may 
collapse,  giving  rise  to  atelectasis  instead  of  a  tempo- 
rary over-distention  or  emphysema.  In  such  cases  there 
is  not  power  enough  on  inspiration  to  overcome  the  ob- 
struction in  the  tubes,  and  the  air  in  the  cells  becomes 
absorbed,  the  oxygen  disappearing  flrst  and  then  the 
carbonic  acid.  Such  a  complication  would  give  some 
dullness  on  percussion  and  is  often  mistaken  for  pni-u- 
monia. 

AusGiiUatlon  usually  reveals  the  presence  of  line 
sub-crepitant  rales  in  great  abundance,  over  both  sides, 
and  esjjecially  low  down  posteriorly,  owing  to  gravita- 
tion of  the  mucus,  in  many  instances,  to  that  ])art. 
Other  rales  may  also  be  present  at  the  same  time.  The 
respiratory  murmur,  if  heard  at  all,  would  be  about 
normal  in  quality,  with  expiration  more  or  less  pro- 
longed, owing  to  the  obstacle  to  the  free  escape  of  air. 
Usually  it  is  so  weak,  however,  owing  to  its  not  being 
freely  conveyed  by  tubes  that  are  obstructed  with 
mucus,  that  it  may  be  obscured  entirely  by  the  rales- 


CAPILLARY   BRONCHITIS.  41 

Sometimes  the  obstruction  is  so  complete  that  it  is 
sui^pressed.  Pectorox)hony  (vocal  resonance  over  the 
chest)  is  usually  normal,  but  may  be  diminished  like 
the  fremitus.  If  exaggerated,  or  markedly  increased, 
it  would  indicate  pneumonia. 

Differential  Diagnosis  of  bronchitis.  This  is  not 
usually  difficult.  Being  a  bilateral  affection  with  no 
physical  sign  of  material  value,  excejDt  the  detection 
of  various  rales  more  or  less  over  both  sides  of  the 
chest  by  auscultation,  it  is  readily  distinguished  from 
acute  lobar  pneumonia  which,  besides  being  usually 
attended  with  severe  constitutional  symptoms,  is  gen- 
erally unilateral  and  confined  to  one  lobe,  usually  the 
lower  lobe  of  the  right  lung.  Moreover,  owing  to  solid- 
ification of  lung  tissue  in  pneumonia,  we  usually  ob- 
tain marked  increase  of  fremitus  on  palpation,  marked 
dullness  on  percussion  over  the  part  affected,  and 
on  auscultation  hear  bronchial  breathing  and  bron- 
chophony, as  will  be  fully  explained. 

In  caj)illary  bronchitis  the  inflammation  may  extend 
here  and  there  in  spots  into  the  air  cells,  giving  rise  to 
lobular  pneumonia,  which  is  also  called  catarrhal  or 
broncho-pneumonia.  It  is  often  difficult  to  detect  mi- 
nute spots  of  lobular  pneumonia.  If  in  the  course  of 
capillary  bronchitis,  respiration  becomes  hurried,  with 
exaggerated  movements  of  the  alfe  nasi  and  rise  in  tem 
perature,  it  is  fair  to  infer  that  lobular  pneumonia  has 
occurred,  even  if  it  be  to  such  a  small  extent  that  other 
signs  are  wanting.  But  if,  in  addition,  there  are  in- 
crease of  fremitus,  dullness  on  percussion,  which  should 
be  gently  performed  on  children  in  order  to  detect  it, 
and  bronchial  breathing  over  one  or   more  spots,  the 


42  PHYSICAL    DIAGNOSIS. 

diagnosis  of  pneumonia  would  be  complete.  Atelecta- 
sis due  to  capillary  bronchitis  would  also  give  some 
dullness  on  percussion,  but  it  would  be  symmetrically 
bilateral  and  there  would  be  sucking  in  of  the  inter- 
costal and  supra-clavicular  spaces  on  inspiration,  with 
no  extra  rise  in  temperature  (see  Atelectasis).  The 
presence  or  absence  of  chlorides  or  albumen  in  the 
urine  in  these  cases  are  of  little  or  no  value  as  aids  to 
diagnosis. 

ASTHMA. 

Asthma  is  described  by  authors  as  a  reflex  neurosis. 
It  is  characterized  by  recurrent  paroxysms  of  violent 
dyspnoea,  due  to  spasm  of  the  muscular  coats  of  the 
bronchial  tubes,  or  tumefaction  of  their  mucous  mem- 
brane from  cai)illary  vaso-motor  disturbance,  or  both. 
It  attacks  both  sexes  at  all  ages,  but  men  are  affected 
by  it  twice  as  often  as  women,  being  more  exposed  to 
the  causes.  It  requires  for  its  production  three  factors : 
(1)  a  sensitive  area  of  mucous  membrane,  (2)  an  abnor- 
mally sensitive  nerve  centre,  and  (3)  an  external  irri- 
tant. Given  all  three  of  these  factors  simultaneously 
and  an  attack  of  asthma  is  i)roduced,  and  it  cannot  be 
produced  by  any  two  without  the  third. 

The  sensitive  area  of  mucous  membrane  may  be  situ- 
ated in  the  naso-pharynx,  bronchial  tubes,  or  stomach. 
The  irritant  applied  to  either  of  these  points  may  be 
reflected  back  to  the  lungs  along  the  pneumogastric 
nerve,  giving  rise  to  naso-pharyngeal  asthma,  bronchi- 
tic  asthma  or  peptic  asthma.  Cardiac  ASthma  is  also 
described,  but  this  would  jiroperly  come  under  the 
head  of  bronchitic  asthma,  owing  to  the  bronchitis  re- 


ASTHMA.  43 

suiting  from  the  heart  disease.  The  second  factor,  the 
abnormally  sensitive  nerve  centre,  may  be  inherited  or 
acquired  by  long-continued  application  of  the  initant 
to  the  sensitive  area  of  mucous  membrane.  Not  only 
this,  but  one  sensitive  area  of  mucous  membrane  may 
give  rise  to  a  second  area,  so  that  naso-pharyngeal,  or 
even  peptic  asthma,  for  example,  may  become  bron- 
chitic  asthma.  Of  external  irritants,  which  constitute 
the  third  factor  in  this  disease,  dust  of  some  sort  is  the 
most  common.  But  there  are  a  great  variety  of  ex- 
ternal irritants,  some  of  them  giving  different  names  to 
the  disease,  as  hay  asthma,  and  the  like. 

Naso-pharyngeal  asthma  is  very  closely  allied  to 
what  is  known  as  hay  fever.  In  the  latter  case  the 
sensitive  area  of  mucous  membrane  in  the  nares  is  situ- 
ated more  anteriorly  than  in  asthma,  and  by  reflex 
action  the  branches  of  the  facial  nerve  are  involved, 
giving  rise  to  lachrymation,  sneezing,  and  other  symp- 
toms of  hay  fever.  Sometimes  hay  fever  and  asthma 
may  occur  at  the  same  time.  The  irritants  in  cases  of 
pejjtic  asthma  are  certain  kinds  of  food,  and  in  bron- 
chitic  asthma,  fog,  cold  with  dampness,  and  changeable 
weather,  often  give  rise  to  an  attack. 

The  physical  signs  of  asthma  during  an  attack  are  as 
follows : 

Inspection  shows  labored  respiration.  Usually  the 
patient  sits  up  and  leans  forward  m  order  to  breathe 
more  freely.  The  shoulders  are  elevated  and  brought 
forward,  the  countenance  is  pale  or  dusky,  and  during 
respiration  the  exj)iratory  act  is  seen  to  be  j)rolonged. 
During  inspiration,  which  is  usually  deferred,  short, 
and  sometimes  jerking,  the  supra-clavicular,  and  supra- 


44  PHYSICAL    DIAGNOSIS. 

sternal  fossae,  scrobiculus  cordis  or  pit  of  the  stomach, 
and  the  intercostal  spaces  are  more  or  less  sucked  in 
and  depressed,  because  the  lungs  do  not  become  inflated 
to  a  degree  corresiDonding  to  the  enlargement  of  the 
thoracic  cavity.  After  the  paroxysm  is  over,  nothing 
abnormal  is  to  be  observed,  unless  there  be  some  com- 
13lication,  as  vesicular  emphysema. 

Palpation. — Rhonchal  fremitus  may  be  'detected 
owing  to  the  rales  (rhonchi)  which  are  present. 

Yocal  fremitus  may  be  unchanged,  or  slightly  dimin- 
ished, owing  to  the  emphysematous  condition  of  the 
lungs  rendering  them  more  refractive  of  sound  than  in 
health.  It  may  be  also  diminished  by  the  obstruction 
in  the  bronchial  tubes  from  spasm  and  mucus,  thus 
rendering  the  tubes  imperfect  conveyors  of  the  voice 
sound. 

Percussion. — Exaggerated  resonance  on  percussion 
is  the  rule,  owing  to  the  emphysematous  condition  of 
the  lungs. 

Auscultation. — Dry  rales  of  various  kinds  are  heard, 
but  chiefly  on  exj)iration,  which  is  much  prolonged, 
while  inspiration  is  so  short  as  to  scarcely  give  time 
enough  for  these  rales  to  be  thoroughly  developed. 
Sometimes  they  are  loud  enough  to  be  heard  by  the 
patient  and  the  friends  in  the  room.  As  the  paroxysm 
declines,  and  increased  secretion  occurs,  various  moist 
rales  may  be  heard,  the  mucous,  sub-mucous,  and  sub- 
crepitant.  Sometimes  moist  rales  are  piesent  with  dry 
rales  from  the  iirst.  The  rales  are  usually  heard  over 
both  sides  of  the  chest,  or  they  may  be  heard  only  on 
one  side,  or  here  and  there  in  spots,  but  changing 
about  from  place  to  place.     The  respiratory  murmur,  if 


ASTHMA.  45 

heard,  would  be  little  changed  in  quality,  if  any,  but 
it  is  usually  obscured  by  rales,  or  it  may  be  weakened 
or  entirely  suppressed,  owing  to  obstruction  in  the 
tubes  and  refraction  in  the  lungs.  The  rhythm  of  res- 
piration is  changed,  expiration  being  much  prolonged. 
The  reason  for  this,  as  well  as  the  emphysematous 
condition  of  the  lungs,  is  the  obstruction  in  the  bron- 
chial tubes  partly  from  spasm  and  partly  from  mucus. 


Fig.  9. — Diagram  showing  Enlargement  of  the  Air-cells  during  a  paroxysm  of 
Asthma  owing  to  spasm  of  the  Bronchial  Tubes. 

The  force  of  inspiration  as  affecting  the  air-cells  is 
greater,  as  already  stated,  than  the  force  of  expiration. 
Hence  air  passes  in  by  the  obstruction  in  the  finer 
tubes  more  easily  than  it  passes  out.  Hence  its  accu- 
mulation in  the  cells  behind  the  obstruction  and  hence 
the  prolonged  effort  in  the  attempt  to  expel  it.  It  is 
not  the  inspiration  of  fresh  air  so  much  as  it  is  the 
effort  to  expel  impure  air  that  constitutes  the  chief 
difficulty  in  a  paroxysm  of  asthma.  Instead  of  inspira- 
tion being  to  expiration  as  4 :1  as  in  health,  the  rhythm, 
as  Walshe  observes,  is  often  reversed  and  is  as  1 :4,  vdth 


46  I'lIYSICAL    DIAGNOSIS. 

expiration  sometimes  loud  and  hissing,  owing  to  spasm 
of  the  bronchi. 


Fig.  10.— Respiration  Murmur  in  Asthma. 

After  the  paroxysm  is  over,  Dronchiul  rales  of  vari- 
ous kinds,  both  dry  and  moist,  may  be  i^resent  for  a 
few  hours,  or  even  several  days. 

Pectorophony  (vocal  resonance)  may  be  normal  or 
somewhat  diminished  like  the  fremitus. 

Differential  Diagnosis. — Proper  attention  to  the 
physical  signs  and  history  of  the  case  will  usually  en- 
able one  to  make  the  diagnosis  of  asthma  with  cer- 
tainty. The  suddenness  of  its  onset  and  departure, 
the  labored  breathing  with  expiration  markedly  pro- 
longed, the  rales  so  abundant  and  loud,  the  absence  of 
purulent  expectoration  and  fever,  and  the  suddenness 
with  which  it  sometimes  yields  to  remedies,  at  once 
distinguish  it  from  bronchitis  of  any  kind.  In  em- 
physema the  dyspno'a  is  constant  instead  of  paroxys- 
mal, owing  to  organic  change,  besides  other  physical 
signs  described  in  connection  with  that  disease  (see 
Emphysema).  In  some  cases  of  heart  disease  there  are 
paroxysms  of  dyspnoea,  but  they  are  usually  shorter 
than  those  of  asthma  and  are  unattended  with  the 
characteristic  prolonged  expiration  of  the  latter  dis- 
ease. In  spasmodic  and  other  affections  of  the  larynx 
there  is  change  in  the  voice,  and  if  wheezing  be  present, 
it  is  located  at  that  point.  Moreover,  in  laryngeal 
spasm,  inspiration  and  not  expiration  is  prolonged  and 


EMPHYSEMA.  47 

labored.  This  may  be  true  of  i)olypus  in  the  trachea. 
In  pulmonary  ffidema  there  is  dyspnoea,  but  there  is 
also  some  dullness  on  percussion  over  the  seat  of  the 
oedema,  which  is  usually  situated  on  both  sides  at  the 
most  dependent  portion  of  the  lungs  posteriorly.  Over 
the  same  region  also  may  be  heard  liquid  crepitant 
rales  at  the  end  of  inspiration.  The  dyspnoea,  instead 
of  being  sudden  or  paroxysmal,  comes  on  gradually, 
increasing  with  the  oedema,  which  may  be  due  to  heart 
disease  or  associated  with  dropsy.  In  hydrothorax, 
which  is  a  symptom  of  general  dropsy,  there  is  flatness 
on  percussion  over  the  pleural  cavities  (up  to  the  level 
of  the  fluid)  instead  of  extra  resonance,  and  the  dys- 
pnoea gradually,  but  steadily  becomes  more  and  more 
urgent  with  increase  of  the  droiDsy,  as  in  oedema. 
In  pulmonary  hypostasis  occcuring  in  old  age  with 
enfeebled  heart,  the  dyspnoea  is  like  that  due  to 
oedema. 

EMPHYSEMA   OF   THE    LUNGS. 

Emphysema,  or  inflation  of  the  lungs,  is  of  two  classes : 
(1)  interstitial,  where  the  air  escapes  through  rupture 
into  the  interstitial  pulmonary  tissue;  (2)  vesicular, 
where  there  is  excess  of  air  in  the  pulmonary  vesicles, 
causing  them  to  be  abnormally  distended. 

Interstitial  emphysema  (inter-lobular,  extra-vesicu- 
lar, extra-alveolar)  occurs  from  rupture  of  the  walls  of 
the  air-cells  as  in  the  expiratory  efforts  of  violent 
coughing,  in  whooping-cough  for  example,  also  from 
parturient  efforts,  blows,  falls,  and  wounds  of  the  lungs 
from  various  causes.  Or  it  may  occur  in  connection 
with  softening  and  breaking  down  of  tubercle.    The 


48  PHYSICAL    DIAGNOSIS. 

air  escapes  into  the  connective  tissue  of  the  Inngs  be- 
tween the  lobules  and  under  the  pleurae.  Sometimes 
it  passes  through  the  posterior  mediastinum  into  the 
subcutaneous  tissues  of  the  neck,  face,  and  sides,  where 
it  crepitates  under  the  hand  during  palpation.  It  is 
impossible  to  make  a  diagnosis  unless  the  air  reaches 
the  subcutaneous  tissue,  and  in  no  case  is  there  any 
special  treatment  for  it.  The  escaped  air  soon  becomes 
absorbed. 

Vesicular  (alveolar)  emphysema  consists  of  two  vari- 
eties: (1)  vicarious  emphysema,  and  (2)  general  em- 
physema. 

Vicarious  (compensating)  emphysema  affects  one  lung 
or  part  of  a  lung  from  over  work  due  to  crippling  of 
the  other  lung  or  part  of  lung.  In  old  pleurisy,  for 
instance,  where  extensive  effusion  or  adhesions  renders 
the  affected  side  almost  immovable,  the  other  lung  be- 
comes vicariously  emphysematous  from  over  work.  In 
lobular  pneumonia  or  collapse  of  some  air-cells,  other 
air-cells  near  by  may  become  emphysematous  in  the 
same  way.  Even  in  acute  lobar  pneumonia  the  un- 
affected lobes  of  the  same  side  may  become  temporarily 
or  acutely  emphysematous  to  a  certain  extent.  In  pul- 
monary consumption  also,  crippling  of  certain  areas  of 
lung  tissue  may  give  rise  to  slight  emphysema  of 
others;  not  marked,  however,  as  respiration  in  con- 
sumption is  usually  shallow  and  rapid,  and  the  volume 
of  blood  much  diminished.  All  vicarious  emphysema 
is  evidently  brought  about  by  excessive  inspiration. 
There  is  no  obstruction  to  expiration  necessarily,  and 
the  patient  endeavors  to  inhale  as  much  air  as  if  both 
lungs  were  intact.     Hence  inspiration  is  overdone,  with 


EMPHYSEMA.  40 

consequent  abnormal  distention  of  the  remaining  vesi- 
cles, and  the  resulting  vicarious  emphysema  w^ill  be 
acute  or  chronic  according  to  the  condition  that  gives 
rise  to  it. 

General  (substantive)  emphysema  is  also  of  two  vari- 
eties: (1)  small-lunged  and  (2)  large-lunged  emphysema. 

Small-lunged  emphysema  (atrophous,  phthisical,  se- 
nile) is  usually  found  among  those  well  advanced  in 
years  and  it  may  or  may  not  follow  the  large  lunged 
variety.  The  volume  of  the  lungs  has  become  much 
reduced  owing  to  atrophy  of  the  intercellular  tissue, 
though  the  air-cells  have  become  larger,  in  many  cases, 
by  coalescence.  It  is  simply  a  condition  mostly  be- 
longing to  old  age. 

,  General  large-lunged  (hypertrophous)  vesicular  em- 
physema remains  for  consideration.  It  is  a  very  seri- 
ous disease  and  occurs  in  men  more  frequently  than  in 
women,  the  former  being  more  exposed  to  the  causes ; 
and  in  northern,  cold,  changeable  climates  more  fre- 
quently than  in  warm  regions  of  a  uniform  tempera- 
ture, owing,  perhax)s,  to  the  greater  prevalence  of  bron- 
chitis and  asthma  in  the  former.  Owing  to  the  length 
of  time  required  to  produce  the  disease,  it  is  rarely 
seen  before  thirty  years  or  middle  life.  Fat  people 
appear  to  be  more  predisposed  to  it  than  the  thin. 
Heredity  undoubtedly  plays  an  important  part  among 
predisposing  causes.  The  disease  is  usually  brought 
about  in  one  of  four  ways:  (1)  by  obstructed  forcible 
expiration,  (2)  forced  insiDiration,  (3)  deformity  of  the 
chest,  and  lastly  (4)  by  inherited  predisposition. 

(1)  Obstructed  forcible  expiratory  effort  is  by  far  the 

most  frequent  cause.    For  this  reason  it  is  found  among 
4 


50  PHYSICAL    DIAGNOSIS. 

laborers  who  are  engaged  habitually  in  haivy  lifting 
or  straining.  In  this  act  the  glottis  is  closed  and  the 
abdominal  muscles  are  contracted  upon  the  intestines 
with  great  power,  which  forces  the  diaphragm  up  and 
compresses  the  air  into  the  upper  lobes  of  the  lungs, 
so  that  in  such  cases  the  upper  lobes  are  chiefly  affected, 
particularly,  according  to  Flint,  the  left.  In  the  same 
way  players  on  wind  instruments  and  persons  affected 
with  chronic  bronchitis,  especially  the  dry  bronchitis 
associated  with  gout,  in  which  violent  fits  of  coughing 
habitually  occur,  may  have  the  disease.  The  act  of 
coughing  simply  consists  of  more  or  less  sudden  and 
violent  expiratory  efforts  with  the  glottis  closed.  Chil- 
dren not  infrequently  have  more  or  less  temporary  em- 
physema from  whooping-cough. 

(2)  In  some  cases  the  disease  is  caused  by  forced 
inspiration.  Here  a  chronic  bronchitis  extending  to 
the  smaller  tubes  precedes  the  emj)hysema  instead  of 
being  developed  afterward.  Inspiration  being  more 
forcible  than  expiration,  as  far  as  the  air-cells  are  con- 
cerned, the  air  passes  in  by  the  obstruction  of  viscid 
mucus  more  easily  than  it  j^asses  out,  so  that  it  accu- 
mulates in  the  air-cells  and  distends  them.  In  these 
cases  we  find  the  lower  portion  of  the  thorax  enlarged 
sometimes,  as  well  as  the  upper. 

(3)  According  to  Freund,  in  some  oases  the  character- 
istic deformity  (barrel  shape)  of  the  chest  in  large- 
lunged  emphysema  occurs  first,  the  lungs  afterward 
becoming  distended  so  as  to  fill  up  the  vacuum.  Such 
cases,  however  common  in  Germany,  are  very  rare  in 
America,  if  indeed  they  ever  occur.  In  some  cases  of 
deformity  of  the  chest,  due  to  rickets,  for  instance,  or 


EMPHYSEMA.  51 

curvature  of  the  spine  from  some  cause,  a  local  em- 
physema may  occur,  one  lung  or  part  of  a  lung  becom- 
ing distended  to  fill  out  one  side  or  portion  of  the 
thoracic  cavity  enlarged  by  bulging. 

(4)  Lastly,  in  certain  instances  the  disease  may  occur 
without  any  mechanical  or  other  known  cause,  but  is 
simply  due  to  inherited  predisposition.  This  consists 
in  an  inherent  weakness  of  the  cell  walls,  perhaps  from 
defective  innervation  and  nutrition,  and  they  yield,  in 
the  ordinary  avocations  of  life,  without  any  abnormal 
force  applied. 

The  dyspnoea  and  abnormal  state  of  the  heart  that 
necessarily  accompany  marked  cases  of  this  disease  re- 
quire brief  notice. 

There  are  three  factors  in  the  production  of  the  dys]3- 
noea:  (1)  rigid  dilatation  of  the  thorax,  (2)  loss  of  ca- 
pillary area  in  the  lungs,  and  (3)  crippling  of  the  dia- 
j)hragm.  The  lung  tissue  has  lost  its  resiliency  and  the 
costal  cartilages  have  become  permanently  elevated, 
everted,  and  hardened,  the  spaces  between  them  being 
widened.  They  have  lost  their  elastic  recoil,  so  that  the 
chest  is  in  a  state  of  rigid  dilatation.  For  this  reason 
air  is  not  expelled  properly,  and  impure  air,  therefore, 
accumulates  in  the  lungs  causing  dyspnoea.  In  the  sec- 
ond place,  many  capillary  blood-vessels  in  the  lungs  be- 
come obliterated  by  over  stretching.  Indeed  many  of 
the  alveolar  septa,  on  which  clusters  of  these  capillaries 
hang,  undergo  wasting  and  perforation,  and  finally  dis- 
ajDpear.  From  loss  of  capillary  area  the  blood  is 
brought  in  less  quantity  in  contact  with  the  air  in  the 
ceUs,  impure  as  it  is.  This  second  factor  is,  therefore, 
a  potent  one  for  the  production  of  dyspnoea.     More- 


52  PHYSICAL    DIAGiSrOSIS. 

over  as  the  blood  now  has  fewer  channels  left  for  it  in 
Avhicli  to  pass  through  the  lungs,  the  right  ventricle  of 
the  heart  has  more  work  thrown  back  on  it  and  hence 
becomes  enlarged  (dilated  and  hypertrophied).  As  the 
disease  progresses,  should  relative  insufficiency  of  the 
tricuspid  valves  ensue,  jugular  pulsation  and  cardiac 
dropsy  may  occur.  Lastly,  the  crippling  of  the  dia- 
phragm is  probably  the  most  important  factor  in  the 
production  of  dyspnoBa.  The  volume  of  the  lungs 
being  increased  sometimes  enormously,  the  diaj)hragm 
is  permanently  pushed  doAvn,  as  is  also  the  heart. 
0^^dng  to  more  or  less  gastro-intestinal  catarrh  from 
passive  hj^ersemia  due  to  obstruction  to  the  venous 
circulation,  there  is  always  more  or  less  dyspepsia  ^^'ith 
wind  in  the  stomach.  The  diaphragm,  the  most  impor- 
tant muscle  of  respiration  a  man  possesses,  is  thus  put 
between  two  splints.  From  want  of  use  it  becomes 
atrophied. 

The  physical  signs  of  general  large-lunged  (hyper- 
trophous)  emphysema  are  as  follows : 

Inspection. — The  countenance  may  be  more  or  less 
dusky  or  cyanotic  in  proportion  to  the  extent  and 
progress  of  the  disease.  In  the  later  stages  jugular 
pulsation,  due  to  tricuspid  insufficiency,  may  be  ob- 
served at  the  root  of  the  neck  on  the  patient's  right 
side  (see  Jiigular  Pulsation).  As  obstructed  forcible 
expiratory  effort  is  the  most  frequent  cause,  so  the 
upper  intercostal  spaces  are  usually  seen  to  be  widened 
owing  to  the  fixed  elevation  and  eversion  of  the  upper 
costal  cartilages  and  ribs,  like  the  elevated  slats  of  a 
shutter.  The  upper  part  of  the  sternum  is  prominent, 
bulging  forward,'  so  as  to  increase  the  antero-posterior, 


EMPHYSEMA.  53 

or  sterno-vertebral  diameter.  The  shoulders  are  ele- 
vated and  brought  forward  owdng  to  habitual  dyspnoea, 
and  the  spinal  column  is  more  or  less  anteriorly  curved. 
The  whole  makes  up  the  so-called  barrel-shaped  chest. 
Where  the  disease  has  been  caused  by  forced  inspira- 
tion, the  lower  portion  of  the  thorax  is  also  enlarged 
with  widening  of  the  lower  intercostal  spaces  also. 

Epigastric  pulsation,  due  to  enlarged  and  lowered 
right  ventricle,  is  usually  noticeable.  The  apex-beat 
is  generally  carried  downward  and  outward,  but  fre- 
quently cannot  be  found,  being  buried  under  lung  tis- 
sue. During  forced  respiration  the  thorax  moves  up 
and  down  more  or  less  like  a  fixed  case,  instead  of  ex- 
panding and  contracting  as  in  health.  During  the  effort 
of  deep  inspiration  the  tupra-clavicular  spaces  may  be 
drawn  in,  the  lungs  not  expanding  any  more  while 
the  thoracic  walls  are  raised  up.  During  \T.olent  cough- 
ing a  tumor  is  sometimes  seen  to  rise  up  from  each  of 
the  flattened  supra-clavicular  fossse.  This,  according 
to  Memeyer,  is  due  to  the  sudden  filling  up  of  the  si- 
nuses of  the  jugular  veins  during  coughing,  which  im- 
mediately become  empty  when  the  cough  ceases.  It  is 
more  probably  due  to  lung  tissue  suddenly  distended 
u^Dward  during  violent  coughing. 

Palpation. — Tlie  lungs,  owing  to  distention  of  the 
air-cells,  become  more  positive  refractors  or  diffusors 
of  sound  than  in  health.  Hence  the  vocal  fremitus  is 
usually  diminished,  and  sometimes  even  absent.  More- 
over, owing  to  bronchitis,  which  is  almost  invariably 
present  in  emphysema,  either  as  a  cause  of  the  disease 
or  result  of  the  obstruction  to  the  pulmonary  circula- 
tion, the  bronchial  tubes  may  be  more  or  less  obstructed 


64  PHYSICAL    DIAGNOSIS. 

with  mncus,  thus  rendering  them  imperfect  conveyors 
of  sound.  Rigidity  of  the  chest  walls  and  loss  of  resili- 
ency of  lung  tissue  also  lessen  the  vibrations. 

If  the  bronchitis  gives  rise  to  such  complications  as 
peri-bronchial  thickening,  with  spots  and  threads  of 
interstitial  induration,  the  fremitus  will  be  increased 
over  corresponding  localities,  on  account  of  the  more 
homogenous  and  better  conaucting  medium  for  the 
voice  sound  (see  Solidified  Lung  Tissue). 

Epigastric  pulsation  is  usually  felt,  and  sometimes 
the  apex-beat  of  the  heart  displaced  down  and  out. 
According  to  some  authors  it  is  carried  inward  toward 
the  epigastrium,  but  it  is  difficult  to  see  how  it  could 
get  there  unless  the  heart  be  raised  up.  The  cardiac 
pulsations,  and  consequently  the  radial  pulse,  are  often 
intermittent  in  this  disease,  owing  perhaps  to  the  ex- 
tra work  thrown  on  the  heart,  so  that  it  has  to  rest 
every  now  and  then.  Dyspepsia,  due  to  gastric  venous 
congestion,  and  acting  reflexly  along  the  pneumogas- 
tric  nerve,  may  also  cause  it. 

Percussion. — Resonance  is  exaggerated  on  percus- 
sion, especially  over  the  upper  lobes  in  front  and  par- 
ticularly on  the  patient's  left  side.  Flint  terms  this 
resonance  vesiculo-tymj^anitic.  That  is  to  say  it  is 
neither  purely  vesicular  nor  tympanitic,  but  a  mixture 
of  the  two.  Biermer,  of  Zurich,  Switzerland,  calls  it 
band-box  resonance.  This  is  especially  the  case  over 
the  lower  posterior  and  left  lateral  regions.  The  pitch 
of  the  percussion  note  in  this  disease  is,  according  to 
some  authors  high,  while  others  maintain  that  it  is  low. 
The  truth  is  the  pitch  varies  in  different  cases  accord- 
ing to  the  tension  of  the  walls  and  the  volume  of  air 


EMPHYSEMA. 


55 


contained.  If  the  walls  are  tense  without  much  in- 
crease in  volume  of  air  the  pitch  will  be  high.  If  vol- 
ume is  greater  in  proportion  to  tension  the  pitch  will 
be  low.  But  the  quality  will  be  the  same  in  all  cases. 
Variations  in  pitch,  while  the  quality  is  the  same,  may 
be  simply  illustrated  in  a  number  of  ways.    The  bass 


Fig.  11.— General  Hypertrophous  Vesicular  Emphysema. 

drum,  for  instance,  yields  a  lower-x)itched  tympanicity 
than  the  snare  drum,  yet  the  quality  of  tympanicity  is 
the  same  for  both.  Drums  of  the  same  size  with  equal 
tension  elicit  tympanicity  on  percussion  and  the  pitch 
of  the  note  will  be  the  same  for  all.  But  if  the  tension 
varies  the  pitch  will  differ  accordingly,  greater  tension 
producing  higher  pitch  than  if  the  tension  be  dimin- 
ished.    The  same  drum  will  give  a  higher  or  lower 


56  PHYSICAL    DIAGNOSIS. 

j)itched  note  on  percussion,  according  as  the  head  is 
tightened  or  loosened.  The  quality  of  the  note  in 
every  case,  however,  will  be  tympanitic. 

The  superficial  area  of  cardiac  dullness  is  diminished 
or  may  be  absent  altogether,  only  deep  dullness  on 
forcible  percussion  remaining. 

In  certain  cases  of  atroj^hous  emphysema  in  advanced 
life,  with  hardened  costal  cartilages  and  peri-bronchial 
thickening  from  long-continued  bronchitis,  the  per- 
cussion note  in  some  places  may  be  dull  or  even  wooden 
in  character,  especially  if  the  percussion  be  gentle. 

Auscultation. — The  lungs  being  more  positive  refrac- 
tors of  sound  even  than  in  health  the  respiratory  mur- 
mur will  be  weakened,  and  if  the  bronchial  tubes  are, 
in  addition,  obstructed  by  mucus,  owing  to  the  bronchi- 
tis usually  present,  the  respiratory  murmur  may  be 
absent.  Not  unfrequently  it  is  obscured  by  bronchial 
rales  of  various  kinds.  When  the  murmur  is  audible 
the  inspiration  is  somewhat  shorter  than  in  health  by 
being  deferred,  that  is,  the  first  part  of  inspiration  is 
not  heard,  being  too  feeble.  It  is  somewhat  lowered  in 
jiitch  usually  and  is  continuous  with  expiration,  which 
is  often  prolonged,  not  so  much  from  obstruction  as 
from  the  weakening  of  the  expiratory  forces.  The 
diaphragm  is  permanently  depressed,  the  pulmonary 
tissue  has  lost  its  resiliency  and  the  costal  cartilages 
their  elastic  recoil.  These  expiratory  forces  have  be- 
come so  weakened,  therefore,  that  expiration  has  to  be 
performed  chiefly  by  contraction  of  the  muscular  coats 
of  the  bronchial  tubes,  which  are  non-striated  or  invol- 
untary muscular  tissue,  and  have  become  more  or  less 
h57)ertrophied.    Consequently  expiration  is  prolonged, 


EMPHYSEMA.  57 

but  otherwise  it  is  relatively  the  same  as  in  health, 
being  lower  in  pitch  than  inspiration  and  blowing  in 
quality.  Should  spasm  of  the  tubes  exist  due  to 
asthma,  with  which  the  disease  is  frequently  associated, 
the  expiration  will  be  about  four  times  longer  than  in- 
spiration, otherwise  it  will  not  be  so  much  prolonged. 

Owing  to  the  distended  condition  of  the  lungs  the 
heart  sounds  are  usually  muffled  and  feeble.  But  on  ac- 
count of  hypertrophy  of  the  right  ventricle  the  second 
sound  of  the  heart  may  sometimes  be  heard  more  dis- 
tinctly (accentuated)  over  the  pulmonary  than  the  aor- 
tic inter-space.  As  dilatation  of  the  ventricle  progres- 
ses, however,  the  accentuation  becomes  less.  Should 
tricuspid  insufficiency  occur,  the  corresponding  muraiur 
may  be  heard  over  the  ensiform  cartilage  (see  Tricuspid 
Regurgitation). 

Bronchial  rales  of  various  kinds,  as  already  stated, 
may  be  present  in  varying  quantity. 

Pectorophony  (vocal  resonance)  is  diminished,  as  a 
rule,  for  the  same  reasons  that  the  fremitus  is  less. 
"When  the  vocal  resonance  and  fremitus  are  increased 
or  vary,  it  is  due  to  some  comjDlication,  as  stated  when 
speaking  of  palpation. 

Differential  Diagnosis. — Pneumothorax,  or  air  in 
the  pleural  cavity,  is  the  only  disease  that  might  be 
mistaken  for  emphysema,  but  even  here  a  careful  at- 
tention to  the  physical  signs  and  history  of  the  case 
renders  the  diagnosis  usually  easy.  General  vesicular 
emphysema  affects  both  lungs,  wdiereas  pneumothorax 
is  nearly  always  unilateral.  Emphysema  is  developed 
gradually,  pneumothorax  comes  on  suddenly.  In  the 
latter  disease  exaggerated  respiratory  movements  are 


58  PHYSICAL   DIAGNOSIS. 

observed  on  the  unaffected  side,  while  these  movements 
on  the  affected  side  are  diminished  or  almost  entirely 
absent,  with  more  or  less  bulging  on  that  side.  In  gen- 
eral emphysema  there  are  the  barrel-shaped  deformity 
of  the  chest,  with  the  thoracic  walls  moving  up  and 
down  as  a  solid  case  during  respiration.  In  general 
emphysema  the  heart  is  displaced  downward  and  usu- 
ally outward,  with  epigastric  pulsation  due  to  the  low- 
ered and  enlarged  right  ventricle.  In  pneumothorax 
the  heart  is  displaced  laterally,  as  a  rule,  and  in  a 
direction  opposite  to  the  pressure.  Percussion  yields 
tympanicity  over  pneumothorax,  whereas  the  resonance 
is  only  exaggerated  (vesiculo-tympanitic,  band-box) 
and  distributed  over  both  sides  of  the  chest  in  general 
emphysema.  On  auscultation  the  respiratory  murmur  is 
changed  in  rhythm  in  emphysema,  and  Aveakened,  but 
in  ^pneumothorax  it  is  usually  absent  over  the  affected 
l^art.  Pneumothorax  from  any  cause  is  always  an 
acute  affection,  coming  on  suddenly  and  lasting  only  a 
few  hours  or  days.  Effusion  then  takes  place  giving 
rise  to  pneumo-hydrothorax  (or  pneumo-pyothorax),  to 
be  detected  by  the  splashing  sound  heard  on  succussion. 
Emphysema  is  more  slowly  developed,  is  usually 
clironic,  and  for  these  and  the  other  physical  signs 
already  mentioned,  vicarious  emphysema,  affecting 
one  side,  is  readily  distinguished  from  pneumothorax. 
Pleurisy,  j)neumonia,  and  hydrothorax,  although  caus- 
ing dyspnoea,  also  yield  dullness  on  percussion  and 
other  physical  signs  altogether  different  from  those  of 
emphysema.  In  phthisis  there  is  also  dyspnoea,  but 
the  signs  of  consolidation  of  lung  tissue  are  entirely 
different  from  those  of  emphysema. 


ATELECTASIS.  59' 

ATELECTASIS. 

Atelectasis  (apneiimatosis,  pulmonary  collapse)  is  a 
disease  characterized  by  collapse  or  imperfect  dilatation 
of  the  pulmonary  vesicles,  and  is  the  very  opposite 
condition  to  emphysema. 

It  is  usually  situated  at  the  periphery  and  not  the 
interior  of  the  lungs,  but  otherwise  the  site  and  extent 
of  area  differ  according  to  the  cause  in  each  particular 
case.  Atelectasis  may  be  congenital  or  acquired.  In 
the  first  place  the  foetal  lungs  are  in  a  j)liysiological 
state  of  atelectasis,  but  this  disappears  as  soon  as  the 
child  is  born  and  breathes  freely,  all  the  conditions 
being  favorable.  Anything,  therefore,  that  interferes 
with  the  resj)iration  of  the  child  at  birth  may  cause 
more  or  less  congenital  atelectasis.  Among  these 
causes  may  be  mentioned  premature  birth,  in  which 
case  there  is  not  only  weakness  of  the  muscles  of  res- 
piration, but  also  a  want  of  irritability  of  the  respira- 
tory centre.  Accidental  plugging  of  the  respiratory 
tract  with  mucus,  binding  the  newly  born  child  too 
tightly,  so  that  the  movements  of  the  diaphragm  are 
interfered  with,  and  prolonged  and  complicated  labor, 
including  accidents  to  the  cord,  may  give  rise  to  con- 
genital atelectasis. 

Acquired  atelectasis  may  be  due  to  (1)  obstruction,, 
(2)  compression,  or  it  may  be  (3)  marasmic. 

1.  Atelectasis  due  to  obstruction  is  sometimes  the 
result  of  cai^illary  bronchitis  occurring  in  weak  infants. 

The  calibre  of  the  tubes  is  diminished  by  the  swollen 
mucous  membrane  and  becomes  obstructed  by  the  se- 
cretion of  fluid  due  to  inflammation.     Owing  to  weak- 


60  PHYSICAL   DIAGNOSIS. 

ness  of  the  inspiratory  muscles  of  such  Aveak  infants 
the  obstruction  is  not  overcome  by  inspiration,  and  the 
air  already  in  the  cells  becomes  absorbed,  the  oxygen 
first,  and  then  the  carbonic  acid.  Collapse  of  the  cells 
results.  But  where  the  child  is  strong  enough,  or 
among  adults,  emphysema  results  instead  of  atelectasis, 
as  inspiration  would  then  be  strong  enough  to  over- 
come obstruction,  biit  the  air  could  not  escape — expira- 
tion being  weaker  than  inspiration  with  regard  to  the  air^ 
cells.  In  these  cases  atelectasis  is  found  on  both  sides 
over  the  lower  and  posterior  parts  of  the  lungs,  and 
extending  usually  in  a  narrow  space  up  by  the  sides 
of  the  spinal  column,  disappearing  toward  the  apices. 

Other  causes  of  obstruction  may  be  blood  clots, 
fibrinous  exudations,  bronchial  stricture,  and  pressure 
on  a  tube  by  enlarged  lymphatics  or  other  tumors. 
The  atelectasis  would  then  occur  in  areas  correspond- 
ing to  the  distribution  of  the  compressed  tubes. 

2.  Atelectasis  may  be  due  to  compression  of  the 
perii)hery  of  the  lungs,  as  in  pleurisy  or  pericarditis 
with  effusion,  enlargement  of  the  heart,  aneurismal  or 
other  tumors,  hydrothorax,  and  deformities.  Here  the 
site  of  the  atelectasis  will,  of  course,  depend  on  the 
cause  in  each  case. 

3.  Finally,  we  may  have  what  Eichhorst  terms  maras- 
mic  atelectasis.  Whatever  diminishes  the  irritability 
of  the  respiratory  centre,  and  weakens  the  muscles  of 
respiration  will  contribute  to  the  atelectatic  state. 
Hence  we  sometimes  find  it  in  typhoid  or  other  pro- 
longed and  wasting  fevers,  paralysis,  and  brain  affec- 
tions. In  such  cases  the  position  of  the  body  should 
not  be  allowed  to  remain  unchanged  during  too  great 


ATELECTASIS.  61 

a  length  of  time.  Otherwise  certain  parts  of  pulmo- 
nary tissue,  from  want  of  respiratory  movement,  become 
more  or  less  devoid  of  air,  which  has  become  partly  or 
w^holly  absorbed,  leaving  atelectasis.  The  most  de- 
j)endent  portion  of  the  lungs  are  the  most  frequently 
affected  in  marasmic  atelectasis. 

Physical  Signs. — In  congenital  atelectasis,  inspec- 
tion usually  shows  retraction  of  the  epigastrium  and 
sinking  in  of  the  intercostal  spaces  on  inspiration. 
This  is  owing  to  the  fact  that  the  lungs  fail  to  expand 
sufficiently  to  fill  up  the  thoracic  cavity  during  inspira- 
tion, and  hence  the  yielding  j)ortions  of  the  chest  walls 
are  sucked  in  by  that  act.  The  breathing  is  rapid  and 
shallow,  with  the  interval  between  inspiration  and  ex- 
piration instead  of  between  expiration  and  inspiration 
as  it  is  in  health.  Palpation  shows  no  increase  of  vocal 
fremitus  as  a  rule,  the  collapsed  air-cells  still  acting  as 
a  refractive  medium  of  sound,  thus  differing  from 
solidification  due  to  inflammation  or  compression,  when 
it  conducts  sound  with  corresponding  increase  of  vocal 
fremitus.  On  gentle  percussion  there  is  some  dullness, 
not  as  much  as  in  solidification.  If  atelectasis  be  ex- 
tensive, slight  tympanicity  from  bronchial  tubes  may 
result.  On  auscultation  the  respiratory  murmur  is 
weakened  or  suppressed  instead  of  being  bronchial,  as 
would  be  the  case  in  solidification  from  inflammation 
or  compression.  This  is  also  due  to  the  fact  that  the 
collaj)sed  cells  refract  sound  instead  of  conducting  it. 
Hence  also,  pectorophony  (vocal  resonance)  is  also 
diminished  or  weakened.  Occasionally,  according  to 
Walshe,  there  is  a  little  dry  rhonchus,  probably  due  to 
coincident  bronchitis. 


62  PHYSICAL   DIAGNOSIS. 

In  acquired  atelectasis  the  physical  signs  depend 
ujion  the  cause.  In  obstruction  and  marasmic  atelec- 
tasis various  rales  may  usually  be  heard,  in  addition  to 
the  signs  already  mentioned,  owing  to  the  bronchitis 
present.  Obstructions  would  also  be  an  additional 
cause  for  weakened  or  diminished  pectorophony,  frem- 
itus, and  resj)iratory  murmur.  But  in  compression 
atelectasis,  the  physical  signs  are  more  like  those  of 
solidified  lung  tissue,  in  which  the  part  affected  be- 
comes a  conductor  instead  of  a  refractor  of  sound  (see 
Physical  Signs  of  Lobar  Pneumonia).  Palpation,  ac- 
cordingly, shows  increased  vocal  fremitus  over  the  com- 
pressed lung,  dullness  on  percussion,  and  bronchial 
breathing  with  bronchoj^hony  on  auscultation.  The 
physical  signs  of  the  cause  of  the  compression,  as 
aneurism,  pleurisy,  and  the  like,  will  also  be  present. 

Differential  Diagnosis. —  Pneumonia  is  attended 
with  fever,  atelectasis  is  not.  Retraction  of  the  e^Digas- 
trium  and  intercostal  spaces  during  inspiration  is  more 
noticeable  in  atelectasis  than  in  pneumonia.  The  bron-  • 
chial  breathing  and  bronchoi^hony  of  pneumonia  are 
not  observed  in  any  but  compression  atelectasis,  and 
then  the  cause  of  the  compression  will  be  apparent. 
The  dullness  on  percussion  in  all  but  compression  ate 
lectasis  is  usually  slight  and  symmetrical.  In  lobar 
pneumonia  it  is  unilateral,  and  in  lobular  pneumonia  a 
spot  of  dullness  on  one  side  does  not  necessarily,  or 
usually,  have  its  exact  counterpart  on  the  opposite 
side,  as  Loomis  truly  states.  According  to  Grailey 
Hewitt,  extensive  deposit  of  miliary  tubercle  may  be 
mistaken  for  atelectasis,  but  the  former  is  accompanied 
by  fever  and  emaciation,  and  perhai)s  the  parents  of 


PULMONARY   CONGESTION.  03 

tlie  child  have  a  tuberculous  his  tor}'.  In  hemorrhagic 
infarction  the  etiology  differs,  and  besides  the  percus- 
sion dullness,  and  rales,  there  is  bloody  expectoration. 
Compression  atelectasis  might  be  mistaken  for  one  of 
its  causes,  pleurisy  with  effusion.  But  the  effusion 
occurs  at  the  bottom  of  the  thorax,  the  compression  of 
lung  above.  Over  the  effusion  there  is  a  well-marked 
line  of  dullness  (or  flatness)  with  diminution  or  absence 
of  the  respiratory  murmur,  vocal  fremitus  and  reso- 
nance, and  these  signs  often  change  with  position  of 
the  patient.  Over  the  compressed  lung  the  fremitus 
and  resonance  would  be  increased,  as  the  compressed 
lung  would  be  a  better  conductor  of  sound  than  in 
health.  The  breathing,  instead  of  being  absent,  would 
be  bronchial.  To  set  all  doubt  at  rest,  exploratory 
puncture  with  the  hypodermic  syringe  may  be  resorted 
to.  In  all  cases  of  compression  atelectasis,  the  cause 
should  be  ascertained,  if  possible. 

PULMONARY  CONGESTION  AND   CEDEMA. 

Pulmonary  hypersemia  (or  congestion)  is  character- 
ized by  excess  of  blood  in  the  lungs  and  may  be  (1) 
active,  (2)  passive,  or  (3)  hypostatic. 

1.  Active  hypersemia  (congestion,  affluxion,  or  flux- 
ion) of  the  lungs,  may  affect  any  part  of  the  lungs.  It 
may  be  caused  by  direct  irritation  of  lung  tissue  either 
from  the  action  of  cold  or  inhalation  of  irritants,  or 
anything  that  will  cause  inflammation.  Or  it  may  be 
due  to  excessive  heart's  action  from  any  caase  like  hy- 
pertrophy, emotion,  stimulants,  or  violent  effort.  It 
occurs  also  as  a  collateral  fluxion,  some  capillaries  be- 
ing over-distended,  due  to  obstruction  in  others,  as  seen 


64  PHYSICAL    DIAGNOSIS. 

in  the  immediate  vicinity  of  inflammatory  foci,  in  pneu- 
monia for  instance.  It  may  also  be  caused  by  rarefac- 
tion of  air  in  the  lungs,  as  occurs  in  croup  on  account  of 
violent  efforts  at  insj)iration  with  the  glottis  obstructed. 

2.  Passive  hypersemia  is  caused  by  mitral  obstruc- 
tion or  regurgitation.  In  the  former  the  blood  is  pre- 
vented from  escaping  from  the  lungs  properly,  and  in 
the  latter  it  is  forced  back  upon  the  lungs.  In  either 
case  the  pulmonary  capillaries  are  over-filled.  This  is 
usually  described  as  mechanical  or  obstructive  hyper- 
gemia,  but  as  it  is  also  passive  there  is  no  necessity  for 
a  separate  description  of  it.  This  form  of  congestion 
often  leads  to  brown  induration  of  the  lungs  (cardiac 
pneumonia  so-called).  Enfeebled  heart's  action,  as  oc- 
curs in  typhoid  fever,  puerperal  fever,  pyaemia,  and 
in  certain  centric  nervous  diseases  favors  the  occurrence 
of  passive  hyperemia,  because  the  left  heart  having 
more  work  to  do  than  the  right,  fails  to  empty  the  pul- 
monary capillaries  as  rapidly  as  they  are  filled.  Hence 
they  become  congested. 

3.  Hypostatic  hypergemia  (congestion)  is  also  a  pas- 
sive congestion  due  to  enfeebled  heart,  but  has  an  addi- 
tional cause  for  its  jDroduction,  and  that  is  the  retention 
of  the  body  in  one  position  for  a  long  time,  as  may  occur 
in  typhoid  fever,  paralysis,  and  fractures,  especially 
among  the  aged,  requiring  them  to  remain  in  one  posi- 
tion for  a  long  time.  Hypostatic  congestion  is  so  named 
because  it  is  a  stasis  of  tlie  under  part,  or  a  congestion 
affecting  the  most  depending  parts,  and  hence  is  usu- 
ally found  posteriorly  in  both  lower  lobes.  Hence  the 
necessity  for  changing  the  position  of  such  patients  oc- 
casionally. 


PULMONAKY    CONGESTION.  65 

The  physical  signs  of  i)iilmonary  congestion  are  simi- 
lar to  those  seen  in  the  first  stage  of  lobar  pneumonia, 
before  any  exudation  has  taken  place. 

Iiujyection. — Dyspnoea  will  usually  be  observed,  and 
it  will  be  marked  in  proportion  to  the  amount  of  con- 
gestion. In  certain  cases  of  hypostatic  congestion, 
however,  owing  to  want  of  irritability  in  the  respiratory 
centre,  as  may  occur  in  the  course  of  protracted  illness 
of  a  typhoid  character,  dyspnoea  may  not  be  x)resent  to 
noticeable  degree.  In  both  passive  and  hypostatic 
congestion  there  may  be  more  or  less  cyanosis.  The 
sitting,  rather  than  recumbent  posture,  is  usually  pre- 
ferred by  the  patient. 

Palpation. — The  vocal  fremitus  is  usually  normal  or 
even  diminished,  as  the  air-cells  are  in  a  slightly  em- 
physematous condition,  owing  to  tumefaction  of  mucous 
membrane  and  diminution  in  calibre  of  the  entrances 
into  the  air  passages,  or  termini  of  the  bronchioles. 
For  this  reason  air  enters  somewhat  more  freely  than 
it  escapes,  as  similarly  occurs  in  asthma.  The  lungs, 
therefore,  being  equally  as  good,  or  better  refractors  of 
sound  than  in  health,  the  fremitus,  as  already  said, 
will  in  some  cases  be  diminished. 

Percussion. — As  might  be  expected  from  the  slightly 

emphysematous  condition  of  the  affected  part,  the  i^er- 

cussion  resonance  may  be  exaggerated.     Yery  often, 

however,  it  is  normal.     Tymj^anicity  is  spoken  of  by 

some  authors,  but  it  is  rare.    That  quality  of  X)ercussion 

sound  might  be  obtained  in  case  of  very  thin  chest 

walls   and  marked  tension  of  the  pulmonary  tissue. 

Should  cracked-j)ot  resonance  be  obtained  it  would 

have  no  connection  with  the  condition  of  the  lungs, 
5 


66  PHYSICAL   DIAGNOSIS. 

but  would  be  due  to  concussion  of  air  in  the  bronchi, 
as  sometimes  occurs  in  children  in  health  and  others 
with  thin  and  yielding  chest  walls,  or  to  concussion  of 
air  in  the  naso-i)harynx. 

Auscultation. —  The  respiratory  murmur  may  be 
weakened  for  obvious  reasons,  or  it  may  be  normal,  de- 
pending on  the  amount  of  obstruction  at  the  entrance 
into  the  air-cells.  Expiration  may  be  slightly  prolonged 
as  in  asthma.  Pectorophony  (vocal  resonance)  would 
be  normal  or  diminished  like  the  fremitus.  The  only 
adventitious  sound  that  would  be  due  to  the  conges- 
tion, would  be  a  very  fine  sibilant  rale  heard  on  expira- 
tion, and  this  may  be  absent.  Any  other  adventitious 
sound  would  indicate  complication,  such  as  oedema,  or 
the  occurrence  of  inflammatory  exudation,  both  of 
which  would  give  rise  to  the  crej^itant  rale  heard  at 
the  end  of  inspiration. 

Differential  Diagnosis. — This,  according  to  Walshe, 
is  based  on  the  association  of  sudden  dyspnoea  and 
general  anxiety  with  the  positive  and  negative  phys- 
ical signs  just  enumerated,  slightly  increased  circular 
measurement  of  the  chest,  due  to  moderate  distention 
of  air-cells,  exaggerated  percussion  resonance,  and  the 
absence  of  signs  of  pleurisy  and  iDueumonia. 

PULMONARY  CEDEMA. 

Pulmonary  oedema,  or  dropsy  of  the  lungs,  occurs 
when  the  i)ulmonary  vesicles  become  the  seat  of  a 
serous  transudation.  In  some  cases  the  fluid  extends 
into  the  smaller  bronchi,  and  in  others  the  interstitial 
tissue  may  become  infiltrated.  As  a  result  of  the  last 
condition  splenization  (Loomis)  of    the  lung  occurs. 


PULMONARY    (EDEMA.  67 

Usually  the  transuded  fluid  is  colorless,  but  sometimes 
it  is  rose  colored  from  being  tinged  with  blood.  Pul- 
monary oedema  is  not  a  primary  disease,  but  is  always 
secondary  to,  and  symptomatic  of,  some  other  condi- 
tion, congestion  from  some  cause  as  already  described, 
or  general  dropsy.  In  the  latter  case  a  transudation  of 
the  watery  parts  of  the  blood  takes  place,  not  from  the 
pressure  of  hyjpersemia  (congestion),  but  from  the  mor- 
bidly increased  permeability  of  the  blood-vessels. 

The  location  of  the  oedema  will  be  influenced  by  the 
cause  in  each  case.  It  may  be  confined  to  a  small 
spot  at  any  part  of  one  lung,  or  it  may  extend  over 
a  lobe  or  entire  lung,  or  even  both  lungs.  Usually, 
however,  it  is  found  low  down  posteriorly  on  both 
sides,  as  the  causes  which  place  it  there  are  most  fre- 
quent— passive  and  hypostatic  congestion — and  also 
because  it  is  more  readily  discovered  there  than  in 
other  localities.  It  may  evidently  occur  in  both  sexes 
at  all  ages. 

Inspection^  as  in  congestion,  shows  more  or  less 
dyspnoea,  according  to  the  extent  of  the  oedema.  The 
dyspnoea  is  more  urgent  than  in  congestion  for  the 
same  amount  of  lung  tissue  involved.  Cyanosis  may 
be  observed  in  some  cases.  The  iDatient  usually  prefers 
the  sitting  posture. 

Palpation. — The  fremitus  is  usually  unchanged,  as 
the  air-cells  still  contain  some  air  and  may  be  even 
weakened  as  in  congestion.  According  to  Walshe, 
however,  in  well-marked  cases  the  fremitus  may  be 
slightly  increased. 

Percussion  yields  more  or  less  dullness  as  a  rule. 
Before  the  oedema  is  well  marked  the  air-cells  may  be 


68  PHYSICAL   DIAGNOSIS. 

slightly  more  distended  with  air  than  before,  as  in  con- 
gestion. For  this  reason  the  percussion  note  may  be 
exaggerated.  But  as  the  cells  become  more  filled  with 
fluid  and  contain  less  air,  the  percussion  note  becomes 
duller.  Tympanicity  and  cracked-x)ot  resonance  are 
among  the  possibilities  here  as  elsewhere. 

Auscultation. — The  respiratory  murmur  and  pecto- 
rophony (vocal  resonance)  are  either  normal  or  weak- 
ened, as  in  congestion,  or  else  increased  in  intensity  in 
well-marked  cases.  During  insiDiration,  loud,  liquid, 
crepitant  rales  are  heard  over  the  sire  of  the  oedema, 
and  this  is  the  chief  physical  sign.  They  are  bubbling 
rales  made  in  the  air-cells  and  are  not  intrapleural. 
In  some  cases,  sub-crepitant  rales  are  also  heard. 

Differential  Diagnosis. — The  chief  points  of  differ- 
ence between  the  physical  signs  of  congestion  and 
oedema  of  the  lungs  are  that  in  oedema,  slight  dullness 
on  percussion  and  loud  liquid  crepitant  rales  on  auscul- 
tation are  obtained.  In  congestion  the  percussion  reso- 
nance is  exaggerated  and  there  are  no  rales  until  oedema 
or  exudation  occurs.  In  the  latter  case  the  crepitant 
rale  is  much  finer  and  not  so  liquid  as  in  oedema. 
From  hydrothorax  oedema  is  distinguished  by  the  fact 
that  the  line  of  dullness  in  hydrothorax  usually 
changes  with  position  of  the  patient.  The  dullness  in 
hydrothorax  is  also  much  more  marked  and  may  even 
be  fiat,  and  crepitant  rales  will  not  be  heard  over  the 
seat  of  the  transudation.  In  capillary  bronchitis  there 
is  more  or  less  fever  and  the  sputa  are  different,  being 
more  tenacious  and  scant  than  in  oedema.  Moreover 
in  capillary  bronchitis  the  percussion  resonance  is  ex- 
aggerated instead  of  dull. 


CHAPTER  III. 

Diseases  in  which  the  breath  and  voice  sounds  are  conducted  to 
the  chest  walls  with  consequent  increased  vocal  fremitus, 
respiratory  murmur  and  pectorophony. — Bronchial  breath- 
ing and  bronchophony. — Solidified  lung  tissue. 

Pneumonia,  or  pneumonitis,  signifies  inflammation  of 
lung  tissue,  and  consists  of  three  varieties  according 
to  the  iDathological  condition:  (1)  lobar,  (2)  lobular,  and 
(3)  inter-lobular,  pneumonia.  Each  of  these  varieties 
is  also  known  by  other  names,  as  will  be  seen.  Hypo- 
static pneumonia,  so-called,  may  be  either  lobar  or 
lobular  (see  Hypostatic  Congestion  of  the  Lungs). 

LOBAR  PNEUMONIA. 

Lobar  pneumonia,  so  named  from  the  fact  that  this 
variety  of  the  disease  usually  affects  a  whole  lobe,  or 
even  more,  may  be  primary  or  secondary.  It  is  com- 
monly an  acute  disease,  although  in  somewhat  rare 
cases  it  may  become  subacute  or  even  chronic.  It  is 
characterized  by  inflammation  of  the  mucous  mem- 
brane lining  the  air-cells,  and  this  inflammation  in 
some  cases  may  even  extend  uj)  into  the  bronchioles, 
the  reverse  process  of  what  occurs  in  lobular  pneu- 
monia. From  the  character  of  the  exudation  it  is  some- 
times called  croupous  pneumonia,  a  term  first  applied 
by  Rokitansky.  According  to  Yirchow  and  others, 
however,  this  term  should  only  be  axox^lied  to  those 


70  PHYSICAL   DIAGNOSIS. 

cases  that  result  from  laryngeal  croup,  and  in  other 
cases,  the  exudation  being  fibrinous,  it  should  be  called 
fibrinous  pneumonia.  On  the  other  hand,  Hoffmann, 
Flint,  and  some  French  authors,  regard  neither  as  cor- 
rect, and  suggest  pneumonic  fever  as  the  true  definition. 
The  disease  is  known  among  the  laity  in  New  England, 
and  other  parts  of  the  United  States,  as  lung  fever. 
Again,  owing  to  its  affecting  the  parenchyma,  or  secre- 
ting structure  of  the  lung,  it  is  sometimes  called  paren- 
chjTuatous  pneumonia,  although  this  is  true  also  of 
lobular  pneumonia. 

Acute  primary  lobar  (croupous,  croupal,  fibrinous^ 
exudative,  parenchymatous)  x^neumonia,  peripneumo- 
nia or  pneumonic  (lung)  fever,  is  said  by  some  to  be  an 
infectious  disease  or  sj)ecific  fever,  of  which  the  lung 
affection  is  only  a  local  manifestation.  By  others  it  is 
claimed  to  be  a  local  inflammation  with  resulting  symp- 
tomatic fever.  It  is  also  yet  a  matter  of  dispute  as  to 
why  it  usually  affects  the  lower  lobe  of  the  right  lung. 
Advocates  of  the  infectious  theory  say  that  the  right 
primary  bronchus  being  larger  than  the  left,  pneumo- 
cocci  are  drawn  into  the  right  lung  in  greater  abun- 
dance than  into  the  left,  and  naturally  drift  downward 
toward  the  most  dei^ending  x^ortions. 

The  order  of  frequency  with  which  the  different  lobes 
are  attacked  is  as  follows:  lower  lobe  of  right  lung, 
lower  lobe  of  left  lung,  middle  lobe  of  right  lung,  upx)er 
lobe  of  right  lung,  upper  lobe  of  left  lung.  Or  it  may 
extend  from  one  lobe  to  another  on  the  same  side,  or 
it  may  attack  two  lobes  on  different  sides.  In  the 
latter  case  it  is  said  to  be  double  pneumouia.  In  cases 
where  an  upper  lobe  is  primarily  attacked,  it  usually 


LOBAR    PNEUMONIA.  71 

occurs  among  the  aged  or  those  addicted  to  intemper- 
ance, especially  just  after  or  during  a  debauch,  pneu- 
monia iDotatorum  (Huss).  Exposure  incident  to  the 
intoxicated  state,  added  to  the  debilitated  condition 
caused  by  hard  drinking,  may  in  some  measure  account 
for  it. 

The  disease  aifects  both  sexes  at  all  ages,  but  men 
more  frequently  than  women,  owing  chiefly  to  differ- 
ence in  habits,  occupation  and  mode  of  life.  In  more 
than  three  thousand  cases  collected  by  Barry,  nearly 
five  times  more  men  than  women  were  affected.  The 
proportion  is  usually  estimated  at  about  three  to  one. 
According  to  Schramm  this  proportion  is  reversed  in 
old  age.  However  this  may  be,  it  appears  that  the  dif- 
ference is  not  so  marked  at  those  ages  when  the  sexes 
live  under  similar  conditions. 

In  regard  to  age,  according  to  GrisoUe,  Wilson  Fox 
and  others,  although  lobular  pneumonia,  when  it  does 
occur,  is  found  chiefly  among  children  and  old  people, 
yet  these  two  classes  are  subject  also  to  lobar  pneumo- 
nia as  well. 

Lobar  pneumonia  is,  according  to  the  same  authors, 
very  frequent  in  infancy,  especially  during  the  first  two 
years  of  life,  less  common  between  infancy  and  twenty 
years  of  age,  quite  frequent  from  twenty  to  forty,  less 
so  from  forty  to  sixty,  and  very  frequent  after  sixty 
years  of  age.  According  to  Loomis,  nine-tenths  of  all 
deaths  after  the  sixty-fifth  year  are  caused  by  lobar 
j)neumonia.  Lowering  vitality  from  any  cause,  such 
as  improper  and  insufficient  food,  exhaustioji  from 
overwork,  intemperance,  or  previous  illness,  and  living 
in  ill- ventilated  and  damp  apartments,  predisposes  to 


72  PHYSICAL    DIAGXOSIS. 

it.  One  attack  also  predisposes  to  a  second  or  more, 
although  subsequent  attacks  are  generally  not  so  severe 
as  the  first. 

Cardiac  diseases  that  obstruct  the  j)ulmonary  circu- 
lation favor  an  attack.  Tlie  disease  is  more  common 
in  variable  climates  than  in  those  of  uniform  tempera- 
ture, and  hence  is  not  met  with  in  the  tropical  or  polar 
but  in  the  temperate  regions,  and  hence  also  it  is  more 
prevalent  at  certain  seasons  of  the  year.  Epidemic 
influenza  appears  to  exert  an  influence  in  the  produc- 
tion of  pneumonia.  Exposure  to  wet  and  draughts 
of  cold  ai^pears  to  act  as  an  exciting  cause  in  some 
cases. 

Inhalation  of  chemical  irritants,  injuries,  and  foreign 
bodies  in  the  air  passages,  may  also  act  as  exciting 
causes  in  a  small  proportion  of  cases.  Tilten  found 
that  in  320  cases,  only  4.5  per  cent,  were  connected  with 
traumatism. 

Secondary  lobar  pneumonia  occurs  as  an  intercurrent 
affection  in  the  course  of  some  exhausting  disease,  as 
chronic  malaria,  Bright's  disease  of  the  kidneys,  dia- 
betes melitus,  and  also  in  such  diseases  as  measles, 
scarlet  fever,  small-pox,  erysipelas,  typhoid  and  tj^phus 
fever,  rheumatism  and  pya3mia. 

Hypostatic;  pneumonia,  when  it  occurs,  succeeds  hy- 
postatic congestion,  which  is  a  passive  congestion  tak- 
ing place  in  the  most  dependent  jiortions  of  the  lungs, 
and  hence  is  frequently  bilateral.  It  may  be  lobar  or 
lobular  (see  Congestion  of  the  Lungs).  It  is  due  to  im- 
perfect cardiac  function  from  valvular  lesion,  or  cardiac- 
enfeeblement  from  some  cause,  and  hence  is  seen  in  tlie 
aged  and  infirm,  or  in  the  course  of  typhoid  fever  or 


LOBAR    PNEUMONIA.  73 

other  exhausting  disease  with  the  body  in  one  i:)osition 
for  too  great  a  length  of  time.  It  may  also  follow  ex- 
cessive loss  of  blood  from  injuries,  parturition  and  the 
like. 

On  the  other  hand,  pneumonia  rarely  affects  the  lungs 
in  emphysema,  probably  on  acount  of  loss  of  capillary 
area  with  diminished  circulation  of  blood  in  the  lungs 
in  that  disease. 

Stages  of  Lobar  Pneumonia. — It  is  usually  divided 
into  three  stages,  not  counting  incubation,  Avhich,  ac- 
cording to  different  authors,  varies  from  a  few  hours 
to  two  or  three  weeks. 

The  first  stage,  or  that  of  congestion,  varies  usually 
from  a  few  hours  to  twenty-four  hours.  The  second 
stage,  or  that  of  red  hepatization  or  solidification,  lasts 
in  ordinary  cases  about  four  or  five  days,  so  that  the 
crisis,  as  indicated  by  the  sudden  fall  in  temperature, 
occurs  from  the  fifth  to  the  eighth  day.  The  third  and 
last  stage  is  that  of  gray  hepatization  or  resolution, 
and  lasts  about  eight  days,  so  that  by  the  end  of  the 
second  week  from  the  commencement  of  the  disease,  the 
patient,  in  ordinarily  favorable  cases,  is  rapidly  con- 
valescent. The  duration  of  the  different  stages,  how- 
ever, is  subject  to  many  variations.  The  i)liysical  signs 
usually  become  apparent  wdthin  twenty-four  to  forty- 
eight  hours  from  the  first  symptoms  of  the  attack,  but, 
according  to  Wilson  Fox,  they  may  be  delayed  three 
or  four  days,  showing  that  the  pneumonia  was  proba- 
bly central  at  first.  If  it  remain  central  no  marked 
lohysical  signs  may  be  observed  at  all,  but  such  cases 
must  be  very  rare.  The  physical  signs  of  the  different 
stages  are  usually  as  follows : 


74  PHYSICAL    DIAGNOSIS. 

Inspection.  First  Stage. — Diminution  of  respira-. 
tory  movements  on  the  affected  side,  and  exaggerated 
respiration  on  tlie  unaffected  side.  Also  marked  ab- 
dominal breathing  if  there  be  no  diaphragmatic  pleu- 
risy and  the  diaphragm  be  left  free.  Pain  in  the  side 
is  usually  j)resent,  and,  if  severe,  the  respiration  Avill 
be  jerking,  the  patient  favoring  the  affected  side  on 
each  inspiration.  The  respiratory  movements  are  in- 
creased in  frequency.  The  apex-beat  of  the  heart,  if 
noticed  at  all,  will  be  in  its  normal  position  unless  dis- 
placed by  some  complication.  The  cheeks  are  usually 
red,  sometimes  only  one,  and  that  on  the  affected  side, 
which  is  simply  a  coincidence.  The  patient  may  lie 
on  the  affected  side  at  first,  so  as  to  restrain  the  move- 
ments of  that  side  if  the  pain  is  severe,  as  well  as  to 
allow  free  motion  on  the  unaffected  side.  Afterward 
the  dorsal  decubitus,  or  half-sitting  posture,  is  usually 
preferred. 

Palpation.  First  Stage. —  The  vocal  fremitus  is  nor-" 
mal  or  even  diminished  before  exudation  commences. 
But  soon  it  becomes  exaggerated  over  the  affected  lobe, 
which  is  rapidly  becoming  a  better  conductor  and  less 
of  a  refractor  of  the  voice  sound,  as  the  air-cells  be- 
come obliterated.  Complications  like  thickened  j^leura, 
or  pleurisy  with  effusion  over  the  site  of  the  pneumonia, 
obstruction  in  the  bronchi  by  pressure  from  some  cause, 
or  from  plugging  with  viscid  mucus,  or  diminishing 
their  calibre  by  the  congestion,  would  cause  the  fremi- 
tus to  be  diminished  or  absent.  The  skin  is  usually 
liot  and  diy,  x>ulse  increased  in  frequency,  80,  100,  120, 
and  the  apex-beat  of  the  heart,  if  felt,  would  be  in  the 
normal  position,  unless  displaced  by  complication. 


PLATE  I. 


Acute  Lobar  Pneumonia — Lower  Lobe  RigKt  Lung.     First  Stage, 
Congestion.     Crepitant  Rale. 


DRAWN     BY  H.MACDONALO     M.O.    N.Y. 


LOBAR    PNEUMOlSriA.  7o 

Percussion.  First  Stage. — Slight  dullness  is  some- 
times observed  early  in  this  stage,  but  sometimes  the 
resonance  may  be  exaggerated  or  even  tympanitic,  and 
occasionally  cracked-pot  resonance  is  noticed  (see  Tym- 
panitic Resonance,  and  Cracked-pot  Resonance).  Gutt- 
mann  and  Eichhorst  account  for  tympanicity  and 
cracked-pot  resonance  in  this  stage  and  the  third  by 
"relaxation  of  the  pulmonary  parenchyma,  which  is 
filled  with  fluid  containing  air,  and  sometimes  to  con- 
cussion of  air  in  the  bronchi."  According  to  Walshe, 
exaggerated  resonance  is  more  frequent  than  slight 
dullness  in  this  stage.  If  the  disease  be  central  or  a 
small  area  involved  there  will  be  no  change  in  the  per- 
cussion note  from  health.  This  diminished  vocal  frem- 
itus and  exaggerated  percussion  resonance  is  due  to 
the  slightly  emj)hysematous  condition  of  the  air-cells 
as  already  mentioned,  on  account  of  obstruction  to  the 
exit  of  air  from  the  air-cells  owing  to  swelling  of  mu- 
cous membrane  in  the  air  passages,  which,  however,  is 
not  sufiicient  to  prevent  the  entrance  of  air. 

Auscultation.  First  Starge. — In  the  earliest  period 
of  engorgement  the  respiratory  murmur  may  be  weak- 
ened, owing  to  obstruction  due  to  swelling  of  the  mu- 
cous membrane.  Soon,  however,  it  begins  to  lose  its 
vesicular  quality  and  becomes  vesiculo-bronchial.  Over 
the  healthy  i)ortions  it  may  be  somewhat  exaggerated. 
Crepitant  rales  are  sometimes,  not  always,  heard  over 
the  affected  lobe.  They  are  heard  at  the  end  of  in- 
si)iration,  very  rarely  on  expiration  (Walshe),  and  are 
fine  crackling  rales  which  sound  like  rubbing  a  lock  of 
hair  between  the  thumb  and  finger  over  the  ear,  or  like 
ihe  crackling  of  fine  salt  when  thi'own  ui^on  the  fire. 


76  PHYSICAL    DIAGNOSIS. 

There  are  two  theories  as  to  their  mode  of  production. 
One  is  that  they  are  produced  in  the  air-cells  by  the  sep- 
aration of  the  agglutinated  cell-walls  at  the  end  of  in- 
spiration or  by  viscid  exudation  and  air  in  the  cells,  or 
stretching  of  the  inter- vesicular  tissue ;  and  the  other 
is  that  they  are  line,  dry,  j^leuritic  friction  rales,  and 
are  only  present  when  the  pleura  is  involved.  During 
the  latter  jynvt  of  inspiration,  when  the  pleural  mem- 
branes rub  together,  the  visceral  and  parietal,  instead 
of  their  gliding  noiselessly  on  each  other  as  in  health, 
there  is  ]3roduced  an  abundance  of  fine  crackling  fric- 
tion rales.  Both  of  these  views  are  still  held  by  differ- 
ent authors.  It  is  more  probable,  however,  that  the 
old  theory  is  the  correct  one,  that  they  are  produced 
in  the  air-cells,  however  closely  they  may  be  imitated 
by  pleuritic  rales.  They  are  uniform  in  size  and  are 
not  changed  by  coughing,  nor  do  they  disappear  until 
the  second  stage,  reappearing  in  the  third,  and  hence 
termed  the  rale  redux.  Pectorophony  (vocal  resonance 
over  the  chest),  like  the  fremitus,  may  be  normal  or 
even  diminished  at  first,  but  soon  it  usually  becomes 
exaggerated. 

The  chief  physical  sign  in  the  first  stage  is  the  crepi- 
tant rale,  heard  at  the  end  of  inspiration  and  over  the 
affected  lobe  when  present,  but  it  is  sometimes  absent, 
and  very  often  the  disease  has  passed  already  into  the 
second  stage  before  the  case  is  seen.  Other  rales  and 
adventitious  sounds  may  be  j^resent,  owing  to  complica- 
tions 

Inspection.  Second.  Stage.  —  This  gives  a  similar 
result  as  in  the  first  stage.  The  respiratory  movements 
are    increased  in  frequency,  being  shallow  and  pant- 


LOBAR    PNEUMONIA.  77 

ing,  more  or  less  restrained  on  the  affected  side  and  in- 
creased on  the  other,  especially  during  a  full  insj^ira- 
tion.  Diaphragmatic  resj)iration  will  be  x>rominent 
unless  restricted  by  pain. 

Palpation.  Second  Stage:— The  vocal  fremitus  is 
usually  markedly  increased  over  the  solidified  lobe. 
This  is  owing  to  the  fact  that  the  solidified  lung 
tissue  affords  an  unbroken,  homogeneous  medium  for 
the  conduction  of  waves  of  sound,  instead  of  refracting 
them,  and  hence  they  reach  the  chest  walls  with  much 
greater  force,  with  consequent  increase  of  fremitus, 
than  in  health,  where  the  air-cells  act  as  a  powerful  re- 
fracting medium.  When,  however,  a  whole  lung  be- 
comes solidified,  with  obstructions  of  the  bronchi,  so 
that  the  voice  sound  cannot  enter  the  lung,  the  vocal 
fremitus  may  be  diminished  or  even  absent.  The  same 
is  true  if  the  bronchi  be  obstructed  from  any  cause,  or 
if  the  thickened  pleura,  or  pleurisy  with  effusion,  exist 
on  the  same  side. 

Percussion.  Second  Stage. — The  note  is  usually 
markedly  dull  in  quality  over  the  affected  lobe,  and 
consequently  the  pitch  is  high,  the  duration  short,  and 
the  intensity  or  amount,  in  the  sense  of  volume  or 
amplitude,  diminished. 

The  percussion  resonance  is  somewhat  exaggerated 
over  the  healthy  lung  tissue,  especially  over  the  adjoin- 
ing border  of  the  next  lobe.  This  is  due  to  a  tempo- 
rary vicarious  emphysema  which  varies  in  different 
cases. 

The  boundaries  of  dullness  and  resonance  in  pneu- 
monia do  not  change  with  position  of  the  patient. 
When  the  whole  lower  lobe  is  affected  the  line  of  dull- 


78  PHYSICAL    DIAGNOSIS. 

ness  in  front  extends  upward  and  outward  along  the 
interlobar  fissure.  Occasionally  the  peroussion  reso- 
nance over  the  solidified  lobe  may  be  tympanitic,  or 
even  cracked-pot,  according  to  Guttmann.  In  the  upper 
lobes,  this  Skodaic  resonance  of  tympanicity,  obtained 
sometimes  while  percussing  over  solidified  lung  tissue, 
(or  even  effusion),  is  due  to  proximity  to  the  primitive 
bronchi  or  the  trachea,  or  both.  Tympanicity  in  such 
cases,  however,  would  be  attended  with  a  sense  of  re- 
sistance on  palpatory  percussion,  which  would  not  be 
felt  on  percussion  in  the  case  of  x)neumothorax,  for  in- 
stance. 

Over  the  lower  lobes  Skodaic  tympanicity  is  often 
due  to  the  fact  that  the  force  of  the  jjercussion  blow 
extends  to  an  empty  stomach  or  transverse  colon,  es- 
pecially in  children,  or  "  relaxed  pulmonary  paren- 
chyma near  the  solidified  portion."  According  to  Gutt- 
mann the  cracked-pot  resonance,  very  rarely  met  with 
in  this  stage,  is  due  to  sudden  expulsion  of  air  from 
the  larger  bronchi  leading  to  the  affected  lobe.  It  might 
probably  be  also  due  to  concussion  of  air  in  large 
bronchi,  or  the  trachea  if  the  seat  of  the  disease  be  in 
the  upper  lobes,  and  is  usually  noticed  in  children  or 
those  with  thin  and  yielding  chest  walls. 

Auscultation.  Second  Stage. — The  respiratory  mur- 
mur as  heard  over  the  solidified  lung  tissue  is  known 
as  broncliial  breathing.  It  is  simply  laryngo-tracheal 
breathing  conveyed  along  the  bronchial  tubes  to  the 
solidified  tissue,  and  by  the  latter  it  is  raised  in  pitch 
and  conducted  with  considerable  force  to  the  chest 
walls,  unmodified  by  air-cells.  It  has,  therefore,  not 
acquired  any  vesicular,  breezy,  or  rustling  quality,  but 


PLATE    II. 


Acute  Lobar  Pneumonia — Lower  Lobe  Right  Lung.  Secqnd  Stage, 
Red  Hepatization  or  Complete  Solidification,  Vocal  Fremitus  markedly 
increased.     Bronchial  Breathing  and  Bronchophony. 


DRAWN     BY  H.MACDONALO     M.D.N.Y. 


LOBAR    PNEUMOISriA.  79 

simi^ly  remains  intensely  tubular  usually,  and  liigli- 
pitclied,  both  on  inspiration  and  exi)iration.  The  lat- 
ter is  usually  higher  j)itched  than  inspiration  because 
of  the  natural  conformation  of  the  larynx.  Inspiration 
is  unfinished,  so  that  this  form  of  respiratory  murmur 
is  said  to  be  divided,  and  the  interval  between  inspira- 
tion and  expiration  will  be  marked  in  proportion  to  the 
amount  of  solidified  lung.  Inspiration  and  expiration 
are,  therefore,  not  continuous,  and  expiration  is  as  long 
as  inspiration,  or  even  longer.  Owing  to  the  shallow, 
panting  respiration  in  pneumonia,  both  the  inspiratory 
and  expiratory  murmurs  are,  however,  rather  short. 

Bronchial  breathing  may  be  represented  somewhat 
by  the  following  diagram: 


Fig.  12. — Bronchial  Breathing. 

Bronchial  breathing  is  more  intense  than  the  normal 
respiratory  murmur  in  the  sense  of  concentrated 
amount.  It  sounds  something  like  blo^\'ing  gently 
across  the  mouth  of  the  stethoscope.  A  close  imitation 
of  it  may  be  obtained,  as  Guttmann  aptly  suggests,  by 
placing  a  piece  of  liver,  which  resembles  hepatized  lung- 
tissue,  in  a  tin  or  other  tube,  with  a  thin  membrane 
over  each  end,  and  listening'  through  it  to  tracheal 
breathing.  Although  Dr.  AValshe  and  others  describe 
this  murmur  as  being  sometimes  blomng  in  quality,  it 
is  always  more  tubular  than  blowing,  and  the  latter  de- 
scription is  misleading.     It  is  always  tubular,  but  more 


80  PHYSICAL    DIAGNOSIS, 

markedly  and  distinctly  tubular  sometimes  than  at 
others. 

Pectorophony  (vocal  resonance)  is  greatly  increased 
in  intensity  in  the  sense  of  concentrated  amount,  not 
volume;  and  as  the  voice  usually  (not  speech)  is  only 
heard,  it  is  called  bronchophony  (bronchial  voice).  This 
term  was  first  applied  by  Laennec,  of  Paris  (about  1820), 
in  contradistinction  to  his  pectoriloquy  (chest- speech). 
The  latter  is  usually  low-pitched  and  refers  to  the  ar- 
ticulate words  often  heard  over  cavities.  But  some- 
times, as  is  well  known,  we  hear  the  articulate  words 
(bronchiloquy)  over  consolidation.  Should  the  voice  be 
whispered,  as  Flint  suggested,  we  should  get  whispered 
bronchophony,  or  whispered  bronchiloquy  over  consoli- 
dated lung  tissue,  as  the  case  might  be. 

Bronchophony  (or  bronchiloquy)  is  necessarily  high- 
pitched,  because  the  voice  sound,  in  case  of  consolida- 
tion, passes  from  one  medium  into  a  denser  medium 
with  shorter  vibrations  and  consequently  raised  pitched. 
Normal  pectorophony  (vocal  resonance)  is  a  dis- 
tant, diffused,  indistinct,  somewhat  low-pitched,  buz- 
zing sound.  Bronchophony  (and  bronchiloquy)  is 
just  the  reverse,  being  near,  concentrated,  distinct, 
and  high-pitched.  When  whispered  it  is  tubular  in 
quality,  cavernous  Avhisper  being  often  low-pitched, 
and  blowing.  In  percussion  the  low  note  is  more  in- 
tense in  the  sense  of  volume,  but  in  bronchophony 
(and  bronchiloquy),  which  is  higli-pitched,  the  intensity 
is  increased  in  the  sense  of  concentrated  amount. 

Should  thickened  pleura  or  effusion  intervene,  both 
bronchial  breathing  and  bronchophony  may  be  weak 
and  distant,  and  the  respiratory  murmur  may  even  be 


LOBAIi    PNEUMONIA.  81 

entirely  inaudible.  So  may  whispered  bronchophony, 
but  if  the  patient  speaks  loud  enough  bronchophony 
will  be  heard.  It  will,  however,  be  distant  and  weak. 
Aegophony  (goat's  voice),  according  to  some  authors,  is 
heard  in  this  stage,  being  due  to  fluid  in  bronchi  that 
are  surrounded  by  solid  tissue.  It  is  quite  rare,  being 
more  often  heard  in  pleurisy  with  effusion  (see  Pleurisy). 

The  heart  sounds  may  be  conducted  to  the  chest 
walls  with  markedly  increased  intensity,  especially  if 
the  disease  be  on  the  left  side.  No  rales  or  other  ad- 
ventitious sounds  are  heard  unless  due  to  comx)licating 
bronchitis  or  other  disease. 

Third  Stage. — During  this  stage  of  gray  hepatization 
or  resolution,  in  favorable  cases,  there  is  a  gradual  re- 
turn to  the  normal  physical  signs.  At  first  they  re- 
semble those  of  the  second  stage,  but  soon  inspection 
shows  a  return  of  the  normal  respiratory  movements 
of  the  chest  walls.  On  palpation  the  vocal  fremitus 
diminishes  over  the  affected  part  until  it  becomes  nor- 
mal, and  the  marked  dullness  on  percussion  gradually 
yields  to  normal  resonance.  Tympanitic  and  even 
cracked- j)ot  resonance,  as  already  explained,  may,  how 
ever,  occur  in  this  stage.  On  auscultation,  bronchial 
breathing  first  becomes  vesiculo-bronchial,  then  normal, 
and  bronchoj)hony  yields  to  exaggerated  pectorophony 
(vocal  resonance)  which  subsequently  becomes  normal. 
Subcrepitant  and  crepitant  rales — the  latter  termed  the 
rale  redux,  or  rale  that  has  come  back,  having  disap- 
peai-ed  in  the  second  stage — are  usually  present  until 
resolution  is  conajDlete.  Abscess  and  gangrene  are  rare 
terminations.  In  both  there  are  signs  of  a  cavity,  with 
symptoms  of  general  collapse.     The  former  is  also  at- 


82  PHYSICAL    DIAGNOSIS. 

tended  with  profuse  expectoration  of  xdus,  the  latter 
with  foetid  prune-juice  expectoration. 

Differential  Diagnosis. — In  cases  of  central  pneu- 
monia with  healthy  x^eripheral  cell  tissue  the  diagnosis 
may  be  very  difficult.  Such  cases  are  comparatively 
rare,  however,  and  in  addition  to  the  history  of  the 
disease  the  character  of  the  sputa  would  be  of  great 
service.  In  oedema  and  hyj^ostatic  congestion  loud 
liquid  crepitant  rales  are  heard,  usually  on  both  sides 
posteriorly  and  low  down,  or  wherever  the  most  de- 
pendent portions  happen  to  be,  and  the  sputa,  though 
blood-stained,  are  abundant  and  watery  instead  of  the 
characteristic  rusty  colored  viscid  sputa  of  pneumonia. 
These  affections,  besides  being  frequently  associated 
with  some  other  disease,  are  also  unaccompanied  by  the 
chill,  pyrexia  and  pain  of  jmeumonia,  and  there  is  slight 
instead  of  marked  dullness,  with  absence  of  bronchial 
breathing  and  bronchophony.  Lobular  pneumonia, 
inter-lobular  pneumonia,  and  tubercular  consumption, 
besides  tumors  of  various  kinds,  aneurismal,  syphilitic, 
or  carcinomatous,  as  well  as  enlargements  of  the  sjjleen 
and  liver,  may  give  more  or  less  signs  of  abnormal 
solidification  within  the  thoracic  cavity,  but  absence  of 
the  characteristic  sputa  of  lobar  i)neumonia,  as  well  as 
the  general  symptoms  of  that  disease,  with  attention 
to  the  physical  signs  as  already  detailed,  will  usually 
lead  to  a  correct  diagnosis.  The  vocal  resonance  and 
fremitus  will  be  diminished  or  absent,  and  bronchial 
breathing  and  bronchophony  will  be  wanting  usually 
over  enlarged  liver  and  spleen. 

Acute  pleurisy  with  effusion  gives  different  physical 
signs  from  pneumonia,  and  it  is  by  these  alone  that  a 


PLATE    III. 


Xr^rf'C^-^ 


Acute  Lobar  Pneumonia — Lower  Lobe  Right  Lung.  Third  Stage, 
Gray  Hepatization  or  Resolution.  Crepitant  (Rale  Redux) and  Subcrepi- 
tant  Rale. 


DRAWN    BY  H.MACDONALO     M.D.H.Y. 


LOBAR  PNEUMONIA.  83 

positive  diagnosis  can  be  made.  Otherwise  it  very 
closely  resembles  pneumonia  in  some  resi)ects.  In 
jDneumonia  the  solidified  lung  tissue  acts  as  a  conduc- 
tor, but  pleurisy  with  effusion  (and  even  thickened 
j)leura)  acts  as  an  interrupter  of  sound,  as  a  diaphragm 
or  partition  placed  between  the  examiner  and  the  pa- 
tient's voice  sound.  Consequently,  while  in  pneumonia 
the  vocal  resonance  and  fremitus  are.  both  markedly 
increased  with  bronchial  breathing  and  bronchial  voice 
(bronchophony),  in  pleurisy  with  effusion  the  vocal 
resonance  and  fremitus  will  be  usually  diminished  or 
even  absent,  as  also  the  respiratory  murmur.  The  line 
of  dullness  or  flatness  in  j^leurisy  increases  downward, 
and,  moreover,  often  changes  with  x^osition  of  the  pa- 
tient, but  does  not  in  pneumonia.  In  cases  of  doubt 
the  hypodermic  syringe  as  an  asj^irator  would  set  the 
matter  at  rest,  but  this  step  is  hardly  ever  necessary. 

Hemorrhagic  infarction  may  be  attended  with  crepi- 
tant and  subcrepitant  rales,  but  it  comes  on  suddenly 
and  usually  in  connection  with  heart  disease,  and  some- 
times pyaemia.  Sudden  dyspnoea  occurring  in  these 
diseases,  with  a  small  circumscribed  area  of  dullness 
surrounded  by  rales,  without  notable  increase  of  tem- 
perature, the  expectoration,  if  any,  being  usually  dark 
colored,  would  indicate  infarction.  Symptoms  of  ty- 
phoid and  typhus  fever,  meningitis,  and  delirium  tre- 
mens, might  be  the  cause  of  over-looking  pneumonia, 
the  real  source  of  the  trouble.  Hence  the  necessity  of 
a  careful  j)hysical  examination  when  such  sjmiptoms 
are  observed  in  children,  old  people,  drunkards,  or 
strangers,  whose  habits  and  previous  condition  are  un- 
known.     Secondary  and   hypostatic  pneumonia  may 


84  PHYSICAL   DIAGNOSIS. 

easily  escape  detection  unless  physical  examination  be 
carefully  resorted  to  and  the  patient  watched. 

LOBULAR  PNEUMONIA. 

Lobular  pneumonia  is  the  inflammation  of  the  lining 
membrane  of  the  air-cells  of  one  or  more  lobules.  The 
difference  between  this  and  lobar  pneumonia  was  first 
pointed  out  by  Barthez  and  Rilliet  in  1838,  although  its 
true  jDathology  was  not  clearly  shown  until  1844,  when 
Legendre  and  Bailly  first  proved  it.  Until  then  it  was 
frequently  confounded  with  atelectasis.  As  it  is  usu- 
ally secondary  to  bronchitis  and  due  to  the  extension 
of  the  latter  into  the  air-cells  here  and  there  in  spots, 
it  is  also  called  Broncho-Pneumonia,  or  Catarrhal  Pneu- 
monia.. From  the  fact  that  it  affects  infants  more  fre- 
quently than  it  does  adults,  it  is  also  called  by  some  In- 
fantile Pneumonia.  This  does  not  imply,  however,  that 
lobar  pneumonia  does  not  also  attack  infants,  for  it  is 
more  common  even  among  them,  according  to  many 
authorities,  than  lobular  j)neumonia.  The  latter  dis- 
ease also  attacks  the  aged,  so  that  it  is  met  with  during 
the  extremes  of  life,  and  among  others  with  enfeebled 
or  crippled  heart  from  some  cause.  It  may  occur,  how- 
ever, at  any  age,  and  with  either  sex.  It  is  not  infre- 
quently met  with  in  connection  with  capillary  bron- 
chitis during  the  course  of  such  diseases  as  measles, 
scarlet  fever,  diphtheria,  small-pox,  and  typhoid  fever, 
and  it  is  sometimes  secondary  to  pyaemia.  Hypostatic 
pneumonia  occurring  in  the  course  of  exhausting  dis= 
eases,  as  already  remarked  when  speaking  of  lobar 
pneumonia,  is  often  of  the  lobular  variety,  with  a  ten- 
dency, however,  to  spread.     From  wliat  has  been  said, 


LOBULAK    PISTEUMOXIA  85 

lobular  pneumonia  may  occur  on  one  side  or  it  may  be 
scattered  about  over  both  lungs. 

The  physical  signs  are  often  obscure  from  the  nature 
of  the  case.  They  are  usually  bilateral,  but  not  neces- 
sarily symmetrical  and  to  the  same  degree. 

Irmpection  usually  shows  in  children  panting  and 
shallow  respiration,  the  inspiration  being  short  and  ex- 
piration somewhat  prolonged.  There  are  exaggerated 
movements  of  the  alse  nasi.  The  upper  portion  of  the 
chest  heaves,  the  lower  portion  and  abdominal  walls 
being  sometimes  drawn  in  during  inspiration,  but  the 
supra-clavicular  and  intercostal  spaces  are  not  drawn 
in  so  much  as  in  atelectasis.  Cyanosis  to  a  variable  de- 
gree may  be  observed  in  cases  where  the  disease  ex- 
tends over  a  considerable  area. 

Palpation. — Increased  vocal  fremitus  may  be  de- 
tected if  the  consolidation  is  sufficiently  extensive,  but 
otherwise  it  will  be  unchanged. 

Percussion  elicits  dullness  in  proi^ortion  to  the 
amount  of  consolidation,  and  the  dullness  will  be  over 
the  seat  of  the  disease,  usually  posteriorly  over  the 
lower  lobes.  It  is  not  infrequently  bilateral,  but  thfe 
dullness  is  not  necessarily  obtained  over  symmetrical 
areas,  as  usually  occurs  in  atelectasis.  Sometimes  exag- 
gerated resonance  due  to  emphysema  of  cells  near  by, 
obscures  the  dullness,  and  even  tympanicity  on  percus- 
sion, as  already  explained,  is  sometimes  obtained.  The 
percussion  should  be  gentle,  and  the  finger  is  the  best 
pleximeter  in  these  cases  to  detect  the  feeling  of  resist- 
ance afforded -by  solidified  lung  tissue. 

Auscultation.— In  addition  to  the  bronchial  rales 
due  to  the  co-existing  bronchitis,  there  may  be  heard . 


86  PHYSICAL    DIAGNOSIS. 

bronchial  breathing  and  bronchoj^hony  if  there  be  suffi- 
cient amount  of  consolidation. 

Differential  Diagnosis. — The  disease,  if  confined  to 
one  or  a  few  small  foci,  may  entirely  escape  detection. 
If,  however,  in  the  course  of  capillary  bronchitis  there 
is  a  sudden  rise  of  temperature  and  increased  dyspnoea, 
it  is  fair  to  infer  that  lobular  pneumonia  to  some  extent 
has  occurred,  even  if  the  usual  physical  signs  are  want- 
ing. If  the  disease  is  extensive,  it  may  be  confounded 
with  lobar  pneumonia  or  atelectasis.  From  the  former 
it  is  distinguished  by  the  absence  of  the  characteristic 
physical  signs  of  that  disease,  extending  over  a  whole 
lobe  on  one  side,  as  well  as  by  the  history  of  the  case 
and  course  of  the  disease.  In  atelectasis,  due  to  capil- 
lary bronchitis,  the  fremitus  is  not  increased,  except  in 
compression,  and  the  dullness  is  not  so  pronounced  as 
in  lobular  pneumonia.  If  a  spot  of  dullness  on  one  side 
does  not  correspond  to  one  on  the  other  side,  according 
to  Loomis,  it  is  in  favor  of  lobular  pneumonia.  Instead 
of  bronchial  breathing  and  bronchox^hony  in  atelectasis, 
due  to  capillary  bronchitis,  the  respiratory  murmur  is 
weakened  or  inaudible,  and  vocal  resonance,  if  changed 
at  all,  is  diminished.  Subcrepitant  rales  are  not  heard 
as  a  rule  over  collapsed  lung  in  atelectasis,  but  nearly 
always  in  lobular  pneumonia.  In  atelectasis  the  signs 
are  often  temporary  and  may  disappear  with  change  of 
position  or  deep  inspiration,  the  cells  becoming  imme- 
diately inflated  with  air  again.  In  pneumonia  also  the, 
temperature  rises,  in  atelectasis  it  does  not. 


INTEELOBULAK   PNEUMOiNIA.  87 


INTERLOBULAR  PNEUMONIA. 

Interlobular  or  interstitial  j)neunionia  is  inflamma- 
tion of  the  interstitial  connective  tissue  of  the  lungs, 
and  is  a  chronic  disease  from  the  first.  Hence  it  is  also 
termed  chronic  pneumonia.  Owing  to  the  shrinkage 
that  follows  usually,  it  was  termed  by  Corrigan  cir- 
rhosis of  the  lungs.  Other  names  are  knife-grinder's 
or  i^otter's  lung,  sclerosis,  schirrus,  and  fibroid  degen- 
eration of  the  lungs.  According  to  Niemeyer,  it  is  one 
of  the  most  frequent  diseases.  In  most  cases,  however, 
it  has  been  confounded  with  fibroid  j)hthisis  (p.  107), 
the  tubercle  bacillus  being  now  found  in  nearly  all 
cases  of  what  was  formerly  supposed  to  be  and  de- 
scribed as  chronic  pneumonia. 

Interlobular  pneumonia  occurs  rarely,  and  is  then 
secondary  to  some  other  disease,  notably  chronic  me- 
clianical  bronchitis  from  inhalation  of  irritating  parti- 
cles, acute  lobar  and  lobular  (broncho-)  pneumonia,  and 
sometimes  pleurisy.  Although  it  may  attack  both 
sexes  at  all  ages,  it  is  more  commonly  found  among 
men  at  middle  life  or  past,  naturally,  from  difference 
in  exposure  to  the  cause  and  length  of  time  usually  re- 
quired for  its  development. 

Occurring  among  coal  miners,  it  is  called  by  Zenker 
anthrakosis  pulmonum.  In  these  cases  the  affected 
portion  of  the  lungs  becomes  black  from  inhalation  of 
coal  dust.  From  inhalation  of  iron  dust,  as  among 
knife-grinders,  it  is  called  siderosis  pulmonum.  In 
other  cases  where  the  dust  inhaled  arises  from   the 


88  PHYSICAL   DIAGNOSIS. 

handling  of  cotton,  grain,  or  tobacco,  for  instance,  or  in 
such  occupations  as  brusli-making,  carpet  or  silk  weav- 
ing, stone  cutting  and  the  like,  the  disease  is  generically 
termed  by  Zenker  pneumonokoniosis. 

In  such  cases  both  lungs  may  be  affected,  but  more 
frequently  it  occurs  only  on  the  right  side,  owing  to  the 
fact  that  the  right  primitive  bronchial  tube  being 
larger  than  the  left,  more  dust  is  inhaled  into  the  right 
lung  than  the  left.  The  disease  may  also  result  from 
extension  of  chronic  pleuritic  inflammation  or  from  a 
prolonged  attack  of  lobar  or  lobular  pneumonia,  neo- 
plastic growths,  and  surgical  injuries.  In  these  cases 
the  interlobular  induration  would  be  situated  accord- 
ing to  the  locality  of  the  original  disease  or  injury.  Fi- 
nally, according  to  Walshe,  syphilis  and  alcoholism,  if 
not  direct  causes,  appear  to  favor  the  development  of 
the  disease. 

An  acute  suppurative  interlobular  (interstitial)  pneu- 
monia sometimes,  but  rarely,  occurs.  It  cannot  be  dis- 
tinguished during  life  from  pulmonary  abscess.  It 
may  occur  in  spots  or  it  may  burrow  along  the  peri- 
bronchial tissue,  and  is  then  called  pneumonia  dis- 
secans (Eichhorst).  It  occurs  in  exhausted  persons, 
and  may  result  from  severe  cases  of  lobar  or  lobular 
pneumonia,  empyema,  or  injuries. 

Interlobulaivpneumonia,  like  flbroid  phthisis,  almost 
invariably  leads  to  more  or  less  dilatation  of  bronchial 
tubes— bronchiectasis.  These  bronchiectatic  cavities 
may  not  be  distinguished  even  anatomically  from  those 
occurring  in  chronic  phthisis,  but  in  the  latter  case  the 
tubercle  bacillus  is  characteristic. 

The  physical  signs  of  this  disease  very  closely  resem- 


PULMONARY    GANGREXE   AND   ABSCESS.  89 

ble  tliose  of  fibroid  phthisis  {]).  131),  to  whicli  the  stu- 
dent is  referred. 

PULMONARY   GANGRENE   AND   ABSCESS. 

Pulmonary  Gangrene,  or  mortification  and  putrefac- 
tion of  lung  tissue,  may  be  circumscribed  or  diffuse, 
affecting  a  lobule,  a  lobe,  or  an  entire  lung.  It  occurs 
more  frequently  perhaps  in  the  course  of  lobar  pneu- 
monia than  any  other  disease,  and  for  that  reason  is 
found  more  frequently  among  men  than  women  be- 
tween twenty  and  forty,  and  on  the  right  side,  espe- 
cially the  lower  lobe  of  the  right  lung.  It  may,  however 
be  found  in  either  sex  at  any  age.  Its  seat  is  on  the 
surface  rather  than  the  interior  of  the  lung.  Lowered 
vitality  from  any  cause,  such  as  improper  or  insufficient 
food,  alcoholism,  and  bad  hygienic  surroundings,  pre- 
dispose to  it.  It  is  therefore  usually  found  among  the 
laboring  and  destitute  classes.  Besides  being  met  with 
in  the  course  of  lobar  pneumonia,  as  already  stated,  it 
may  result  as  an  extension  from  putrid  bronchiectatic 
cavities,  or  septic  bodies  or  food  entering  the  bronchi 
and  undergoing  putrefaction,  as  in  the  case  of  the  late 
Emperor  Frederic  of  Prussia.  Sometimes  it  is  caused 
by  septic  embolism,  as  may  occur  in  diphtheria,  hepatic 
abscess,  epidemic  dysentery,  and  pyaemia,  and  some- 
times it  is  the  direct  result  of  surgical  injuries. 

Inasmuch  as  gangrene  is  preceded  by  inflammation, 
the  physical  signs  are  those  of  solidification  at  first,  as 
already  described,  and  of  broken-down  tissue  resulting 
in  a  cavity  afterward  (see  Cavities,  Phthisis,  Third 
Stage).  As  soon  as  gangrene  occurs,  there  are  symp- 
toms of  collapse,  but  a  positive  diagnosis  cannot  be 


9()  PHYSICAL    DIAGNOSIS, 

made  until  communication  between  broken-down  gan- 
grenous tissue  and  a  bronchial  tube  is  established  so 
that  the  sjiuta  can  be  examined.  The  foetid  odor  and 
prune- juice  color  of  the  sputa  are  unmistakable.  In 
case  of  a  small  area  of  centric  gangrene,  however,  the 
disease  may  entirely  be  overlooked. 

Differential  Diagnosis. — The  j3eculiar  foetid  and 
discolored  expectoration  of  pulmonary  gangrene,  con- 
taining, as  it  does,  decomposed  bronchial  plugs  and 
shreds  of  pulmonary  tissue,  usually  enables  one  to  dis- 
tinguish gangrene  of  the  lungs  from  jDutrid  bronchitis, 
empyema  that  has  ulcerated  into  bronchial  tubes,  ab- 
scess, or  phthisical  cavities. 

The  etiology  of  pulmonary  abscess  is  similar  to  that 
of  pulmonary  gangrene.  In  pneumonia  it  is  rare,  oc- 
curring about  once  in  fifty  cases  according  to  Huss,  but 
more  frequently  in  pneumonia  of  the  upper  than  lower 
lobes,  and  in  this  respect  it  differs  from  gangrene.  The 
physical  signs,  like  those  of  gangrene,  are  the  signs  of 
consolidation  until  communication  between  the  abscess 
and  bronchial  tubes  is  established,  when  there  will  be 
profuse  expectoration  of  pus,  followed  by  signs  of  a 
cavity  (which  see).  There  are  also  symptoms  of  col- 
lapse, as  in  gangrene,  but  not  so  marked. 

CANCER  OF  THE   LUNGS. 

Cancer  of  the  Lungs  may  be  primary  or  secondary — 
usually  the  latter.  In  the  fomier  case  the  cause  is  the 
same  as  that  of  primary  (;ancer  occuriing  in  other  or- 
gans, and  is  unknown.  Heredity  is  probably  the  most 
important  factor  in  its  i)roduction,  although  seventy- 
five  per  cent,  of  all  the  deaths  among  the  Schneebergeii 


CANCER   OF   THE   LUNGS.  91 

Cobalt  miners  is,  according  to  Eiclihorst,  the  resnlt  of 
primary  pulmonary  cancer.  It  develops  among  them  at 
about  the  age  of  forty,  and  after  they  have  been  work- 
ing in  the  mines  for  about  twenty  years.  It  is  thought 
to  be  due  to  the  irritation  produced  by  the  inhalation 
of  arsenic  in  the  cobalt  ore.  For  this  reason,  and  be- 
cause the  right  bronchial  tube  is  larger  than  the  left,  and 
situated  higher  up,  it  affects  the  upper  lobe  of  the  right 
lung  most  frequently,  and  occurs  in  men  oftener  than  in 
women,  and  after  several  years  of  exposure  to  the  cause,, 
as  in  the  case  of  anthrakosis  pulmonum  and  the  like 
(p.  87).  It  infiltrates  the  pulmonary  tissue,  and  not 
infrequently  cancerous  enlargement  of  mediastinal 
glands  co-exist. 

Secondary  cancer  of  the  lungs  follows  cancer  in  some 
other  part.  According  to  Walshe,  other  authors,  and 
my  own  observation,  it  is  secondary  in  the  lungs,  espe- 
cially where  the  testicles  have  been  the  seat  of  the  pri- 
mary affection.  It  usually  affects  both  lungs,  unequally 
of  course,  and  is  nodular,  the  nodules  varying  in  size 
from  a  pin's  head  to  a  child's  head.  In  many  cases 
there  are  evidences  of  cancer  in  other  organs,  various 
glands  being  enlarged.  Encei^haloid  (medullary)  can- 
cer is  the  most  common  form  of  the  disease  in  the  lungs, 
although  scirrhus,  mixed,  and  other  varieties  are  also 
found.  Although  any  form  of  cancer  of  the  lungs 
affects  men  most  commonly  from  twenty  to  forty  years 
of  age,  it  may  be  found  in  both  sexes  at  all  ages. 

There  are  other  neoplastic  growths  that  are  found 
in  connection  with  the  lungs,  but  cancer  is  by  far  the 
most  important.  They  are  fibromata,  lipomata,  en- 
chondromata,  osteomata,  melanotic  tumors,   dermoid 


92  PHYSICAL    DIAGNOSIS. 

cysts,  myxomata  and  licematomata.  They  are  rarely 
distinguished  during  life,  as  the  symptoms  they  pro- 
duce are  v^y  vague. 

The  physical  signs  of  pulmonary  cancer  are  as  follows : 

Inspection. — Retraction  of  the  chest  walls  over  the 
affected  parts  is  usually  noticed,  with  diminution  of 
resj)iratory  movement  on  that  side,  especially  in  case  of 
primary  infiltrated  cancer  of  the  lungs. 

In  the  secondary,  nodular  form,  bulging  of  the  chest 
walls  with  displacement  of  the  heart  may  be  observed, 
if  there  be  a  large  tumor.  The  cancer  may  also  appear 
externally  on  the  chest  walls.  The  sputa  are  reddish- 
brown  or  currant-jelly,  usually,  and  contain  cancer  cells. 

Palpation. — The  vocal  fremitus,  owing  to  consolida- 
tion from  infiltration  or  pressure,  is  usually  increased. 
But  occasionally,  especially  in  the  secondary  or  nodu- 
lar form,  a  large  bronchus  may  be  pressed  upon  by 
the  tumor,  and  the  voice  may  be  so  obstructed  as  not 
to  be  conveyed  by  the  bronchial  tube  to  the  affected 
part.  In  such  a  case  the  fremitus  would  be  diminished 
or  absent  over  the  corresponding  area.  The  same  re- 
sult might  be  obtained  by  complete  displacement  of 
lung  tissue  by  a  large  tumor. 

Percussion. — There  is  dullness,  slight  or  marked, 
according  to  the  extent  of  infiltration  or  size  of  the 
nodides.  It  is  usually  irregular  in  outline  and  does 
not  change  with  position  of  the  patient,  and  sometimes 
extends  across  the  median  line  on  account  of  co-existing 
enlargement  of  mediastinal  glands.  In  case  of  break- 
ing down  of  cancerous  tissue  or  tubercle,  with  which 
it  is  sometimes  associated,  signs  of  resulting  cavity 
would  be  i^resent  (see  Cavity). 


CANCER   OF   THE   LUNGS.  03 

Auscultation. — Owing  to  consolidation  of  lung  tissue, 
due  to  infiltration  or  pressure,  bronchial  breathing  and 
bronchophony  are  usually  heard.  If  a  bronchus  be 
obstructed  by  pressure  from  a  large  nodule,  however, 
the  respiratory  murmur  and  whispered  voice  would  be 
weakened  or  even  suppressed  and  absent  for  a  corre- 
sponding area  to  which  the  tube  is  distributed.  The 
same  result  would  also  be  obtained  in  case  of  displace- 
ment of  lung  tissue  by  a  tumor.  Should  consolidation 
be  incomplete,  vesiculo-bronchial  breathing  and  exag- 
gerated vocal  resonance  only  would  be  heard  over  the 
affected  part.  In  case  a  cavity  is  formed  by  breaking 
down  of  tissue  or  dilatation  of  a  tube,  the  respiratory 
murmur  over  it  would  be  blowing  in  quality,  and  there 
would  be  other  signs  of  a  cavity  (see  Phthisis,  Third 
Stage — Cavities). 

Until  softening  has  occurred,  rales  are  not  commonly 
heard  in  cancer  of  the  lungs. 

Differential  Diagnosis. — Primary  infiltrated  cancer 
may  be  mistaken  for  other  diseases  that  cause  retrac- 
tion of  the  chest,  as  chronic  phthisis,  pleurisy  with 
retraction  after  absorption  of  the  fluid,  and  syphilitic 
infiltration  of  the  lungs.  Either  form  of  cancer  may 
be  mistaken  for  thoracic  aneurism,  especially  as  can- 
cerous enlargement  of  mediastinal  glands  not  infre- 
quently co-exists.  The  secondary  or  nodular  form  of 
cancer  may  even  be  mistaken  for  pleurisy  with  effusion, 
if  the  tumor  be  large  enough,  indeed  they  frequently 
exist  together. 

Fibroid  and  catarrhal  phthisis  usually  begin  in  the 
upper  lobes,  and,  like  2')rimary  infiltrated  cancer, 
may   affect    only    the    right    lung.      But    in    cancer 


94  PHYSICAL   DIAGNOSIS. 

the  disease  runs  a  more  rajjid  course  and  dullness  on 
l)ercussion  may,  as  AValshe  truly  states,  extend  across 
the  median  line  on  account  of  co-existing  cancerous 
mediastinal  growths.  The  sj)uta  in  cancer  are  charac- 
teristic, being  like  currant  jelly  and  containing  cancer 
cells  instead  of  tubercle  bacilli.  The  cancerous  cachexia 
is  soon  established  and  cancer  may  also  appear  else- 
where. In  either  disease  the  heart  may  be  displaced, 
but  it  is  usually  much  more  so  in  phthisis,  especially  of 
the  fibroid  variety.  Pain  and  dyspnoea  occur  earlier 
in  cancer  and  are  also  usually  more  prominent.  On  the 
other  hand,  rales  are  heard  in  the  earliest  stages  of 
phthisis,  especially  of  the  catarrhal  form,  whereas  in 
cancer  they  are  not  usually  heard  before  softening  of 
cancerous  tissue  occurs.  By  that  time  the  cachexia 
and  other  signs  of  cancer,  already  mentioned,  are  so 
well  marked  that  the  diagnosis  is  comparatively  easy. 
As  the  disease  progresses  the  characteristic  cancerous 
sputa  and  absence  of  high  temj)erature  in  cancer  would 
aid  in  a  correct  diagnosis. 

In  chronic  pleurisy  with  retraction  there  is  cough, 
but  with  little  exjiectoration  usually.  The  vocal  fre- 
mitus, respiratory  murmur,  and  \vhisx)ered  voice  in  j^leu- 
ris}'  are  diminished  or  absent,  and  ordinary  vocal  reso- 
nance, or  pectoroiDhony,  is  also  diminished.  There  are 
no  inward  pressure  signs  on  the  trachea  and  a?sophagus 
in  i^leurisy.  The  dullness  in  jDleurisy,  much  more  reg- 
ular in  outline  than  in  cancer,  is  usually  found  at  the 
base  of  the  lungs,  posteriorly,  and  does  not  extend 
across  the  median  line;  and  the  disease  is  generally 
slow  in  its  j^rogress.  The  revei-se  is  usually  true  in 
cancer,  the  physical  signs  of  which,  as  a  rule,  arc  found 


CAXCEIi   OF   THE   LUNGS.  95 

ill  tlie  front  and  upper  part  of  the  tliorax,  rather  than 
XJOSterioiiy  and  Jow  down.  The  history  of  the  case, 
tlie  character  of  tlie  sputa,  the  cacliexia  and  the  greater 
severity  of  the  symptoms  in  cancer  would  also  aid  in 
a  correct  diagnosis.  In  jjleuritic  effusion,  besides  dif- 
ferences already  mentioned,  the  physical  signs  often 
change  with  iDOsition  of  the  patient,  which  probably 
never  occurs  in  case  of  cancer.  Should  the  cancer  give 
rise  to  pleurisy  with  effusion,  the  latter,  according  to 
Bowditch,  is  always  bloody.  The  character  of  the  ef- 
fusion in  doubtful  cases  is  easily  told  by  means  of  the 
hypodermic  syringe. 

In  syjjhilitic  infiltration  there  would  be  the  history 
of  syphilis,  other  syx)hilitic  lesions  would  probably  be 
present,  and  improvement  would  rapidly  follow  anti- 
syj)hilitic  treatment. 

Thoracic  aneurism  usually  occurs  in  men  at  middle 
life  or  past,  or  in  either  sex  in  old  age.  Cancerous  en- 
largement of  mediastinal  glands,  the  lungs  becoming- 
invaded  afterward,  occurs  mostly  in  women  between 
twenty  and  thirty.  But  cancer  of  the  lungs  with  co- 
existing mediastinal  tumors  often  appears  in  men  also 
about  middle  life.  Both  aneurism  and  cancer  may 
cause  dulness  on  percussion  across  the  median  line  and 
inward  pressure  signs,  and  be  attended  by  cardiac  dis- 
placements and  murmurs,  but  in  cancer,  besides  the 
cancerous  cachexia  and  sxouta,  there  are  often  disten- 
tion of  superficial  thoracic  veins,  with  oedema  of  the 
chest,  arms,  and  face,  which  never  occurs  from  thoracic 
aneurism.  Moreover,  in  all  cases  of  cancer  of  the  lungs 
evidences  of  cancer  in  other  organs  may  sometimes  be 
obtained  on  careful  examination. 


96  PHYSICAL    DIAGNOSIS. 

\ 

HEMORRHAGIC   INFARCTION   OF  THE   LUNGS. 

Hemorrhagic  infarction  of  the  kings  is  cu'cnmscribed 
pnhnonary  ai)oplexy  due  to  embolism.  (1.)  Most  com- 
monly there  is  plugging  of  a  branch  of  the  pulmonary 
artery  by  an  embolus,  followed  by  transudation  (dia- 
pedesis)  of  blood  into  the  parts  formerly  supplied  by 
the  obstructed  twig.  (2.)  More  rarely  it  is  produced 
by  rupture  of  a  branch  of  the  pulmonary  artery,  due 
to  intense  liyi)er?emia  around  the  obstruction,  and  fatty 
degeneration  of  the  vessel.  The  blood  in  these  cases, 
according  to  Rindfleisch,  finding  its  way  into  the  air- 
cells  and  bronchi  of  the  part,  rapidly  coagulates  and  the 
process  ceases.  (3.)  Finally,  in  other  cases  no  known 
cause  for  the  infarction  can  be  found,  all  trace  of  an 
embolus  having  disappeared.  After  complete  obstruc- 
tion of  a  twig  of  the  pulmonarj^  artery  by  an  embolus, 
the  parts  beyond  the  plug,  including  air-cells,  bronchi- 
oles, and  interstitial  tissue,  become  the  seat  of  hemor- 
rhagic infiltration,  how?  According  to  Cohnheim,  this 
is  accomplished  by  the  arterial  blood  being  forced  back- 
ward, or  regurgitated,  from  the  capillaries  of  the  pul- 
monary veins  into  the  excommunicated  capillaries  of 
the  obstructed  twig  of  the  pulmonary  artery.  The 
latter  do  not  rupture  usually,  but  allow  a  diapedesis 
(transudation)  of  blood  through  their  walls,  which  have 
become  abnonnally  permeable,  owing  to  the  disturb- 
ance of  their  integrity  by  the  embolism.  Besides  this, 
they  pi'obably  allow  leakage  of  arterial  blood  more 
readily  than  venous  blood  to  which  they  had  been  ac- 
customed. It  was  formerly  thought  that  the  infarction 
in  these  cases  was  always  due  to  rupture  of  capillaries, 


HEMORRHAGIC  INFARCTION  OF  THE  LUNGS.  97 

simply  from  intense  liyperffimia,  as  might  occur  in 
mitral  disease,  without  taking  the  embolus  into  ac- 
count. But  this  did  not  explain  why  the  infarction 
was  limited  to  such  abrux:)tly  and  well-defined  areas, 
sometimes  a  single  lobule.  The  true  exi^lauation  in 
these  cases  is  that,  owing  to  mitral  obstruction  or  re- 
gurgitation, there  follows  sooner  or  later  dilatation  of 
the  right  ventricle.  At  first  it  is  dilated  hypertrophy, 
but  in  time  dilatation  becomes  prominent,  and  not  being 
properly  compensated  by  hypertrophy,  the  blood- 
current  becomes  sluggish.  In  this  condition,  thrombi, 
or  firm  clots  of  venous  blood,  may  form  in  the  right 
heart,  especially  in  the  musculi  pectinati,  of  the  right 
auricular  appendix,  or  between  the  columnse  carnese  of 
the  right  ventricle,  near  the  apex.  From  these  thrombi, 
emboli  becoming  detached,  cause  infarctions  in  the 
lungs  by  their  direct  transmission  along  the  pulmo- 
nary artery. 

Emboli,  besides  originating  in  the  right  side  of  the 
heart,  from  dilatation,  may  enter  the  systemic  venous 
circulation  from  any  p)art  of  the  body,  and,  passing 
through  the  right  heart,  produce  infarction  in  the  lungs. 
In  fractures,  or  other  severe  injuries,  of  the  skull,  af- 
fecting the  diploe,  otitis  giving  rise  to  inflammation 
of  the  petrous  portion  of  the  temporal  bone,  and  throm- 
bosis of  the  cerebral  sinuses  from  any  cause,  emboli 
may  enter  through  the  superior  vena  cava  into  the  right 
side  of  the  heart.  In  like  manner  emboli  may  become 
detached  from  thrombi  formed  in  any  of  the  peripheral 
veins,  as  sometimes  occurs  in  typhoid  or  other  fevers; 
also  in  cases  of  thrombosis  of  uterine  or  ovarian  veins, 


98  PHYSICAL    DIAGNOSIS. 

and  even  the  iliac  or  renal  veins  from  pressure  of  large 
uterine  fibroid  and  other  tumors. 

When  the  emboli  are  septic,  metastatic  abscess  usu- 
ally occurs,  instead  of  infarction,  or  rapidly  follows  it. 

Emboli  originating  in  the  portal  circulation,  as  some- 
times occurs  in  haemorrhoids  or  dysentery,  are  likely  to 
produce  infarctions  in  the  liver.  Those  coming  from 
the  lungs,  or  left  side  of  the  heart,  alfect  the  brain, 
spleen,  or  kidneys. 

Hemorrhagic  infarction  may  only  affect  a  single 
lobule,  or  there  may  be  several  infarctions  simultane- 
ously in  one  or  both  lungs.  From  the  fact  that  the 
branches  of  the  pulmonary  artery  become  smaller  as  we 
approach  the  surface  of  the  lung,  infarctions  are  found 
more  commonly  at  the  periphery  than  in  the  interior 
of  the  lungs.  For  the  same  reason  also,  central  infarc- 
tions are  more  extensive  than  peripheral.  Naturally 
the  infarcted  areas  are  somewhat  pyramidal  in  shape, 
with  their  bases  toward  the  periphery. 

The  physical  signs  of  infarction  are  as  follows : 

Inspection. — There  is  dyspnoea,  which  ux)on  inquiry 
will  be  found  to  have  come  on  suddenly  and  unex- 
pectedly. The  dyspnoea  will  be  in  jDroportion  to  the 
amount  of  infarction.  Where  the  latter  is  small,  it 
may  be  entirely  overlooked.  But  when  extensive,  the 
respiratory  movements  will  be  increased  in  frequency, 
and  the  breathing  may  be  labored.  The  sputa  are 
somewhat  characteristic,  being  brownish-red,  and  darker 
colored  than  those  of  lobar  pneumonia. 

Palpation. — The  vocal  fremitus  is  usually  increased, 
unless  the  infarction  be  central  or  comj)licated  by  pleu- 
risy. 


PULMONARY   APOPLEXY.  99 

Percussion. — There  will  be  dullness  on  percussion 
unless  the  infarction  is  central  or  very  small,  in  which 
cases  there  may  be  little  or  no  dullness. 

Auscultation. — In  case  of  extensive  peripheral  in- 
farction, bronchial  breathing  and  bronchophony  may 
be  heard  over  the  seat  of  the  part  affected.  Crepitant 
and  subcrepitant  rales  are  also  usually  heard.  In  some 
cases  there  may  be  no  physical  signs,  owing  to  the  small 
extent  of  infarcted  area,  its  central  location,  or  existing 
complications,  like  pleurisy,  for  instance.  The  heart 
should  always  be  examined. 

Differential  Diagnosis. — By  means  of  sudden  dysp- 
noea, localized  spots  of  dullness,  if  any  exist,  crepitant 
and  subcrepitant  rales,  and  especially  the  slight  rise  in 
temperature  with  the  characteristic  brownishired  sputa, 
which  last  for  a.  much  longer  period  than  in  pneumo- 
nia, the  co-existence  of  heart  disease,  especially  old 
mitral  obstruction  or  regurgitation,  and  the  etiology  in 
general,  it  is  usually  possible  to  make  a  diagnosis.  The 
sputa  of  cancer  of  the  lungs  resemble  those  of  infarc- 
tion, but  the  former  contain  cancer  cells,  and  there 
would  be  the  cancerous  cachexia,  and  other  signs 
already  mentioned.  According  to  Loomis,  the  sputa 
of  hydatid  disease  of  the  lungs  may  also  resemble  those 
of  infarction,  but  in  the  former  case  the  discovery  of 
hooklets  would  be  decisive. 

PULMONARY  APOPLEXY. 

Pulmonary  apoplexy,  or  escape  of  blood  into  the 
pulmonary  tissue,  may  be  circumscribed  or  diffuse.  In 
the  former  case,  as  we  have  already  seen,  when  due  to 
embolism,  it  is  called  infarction.     But  it  may  also  occur 


100  PHYSICAL    DIAGNOSIS. 

locally  from  causes  wliicli  lead  to  rupture  of  pulmo- 
nary capillaries,  either  by  over-distending  tliem  or  weak- 
ening their  walls,  or  both,  without  embolism.  These 
causes  are  fully  considered  in  speaking  of  hyperemia 
and  hfemoiDtysis  (which  see).  In  diffuse  apoplexy, 
the  pulmonary  tissues  become  more  or  less  destroyed 
by  the  extravasated  blood,  which  has  escaped  from 
rupture  of  one  or  more  large  vessels.  Sometimes  the 
hemorrhage  is  confined  within  the  lung  substance,  at 
other  times,  from  rupture  of,  the  pleura,  the  blood  may 
be  discharged  into  the  pleural  sac. 

Diffuse  pulmonary  apoplexy  may  be  due  to  surgical 
injury,  or  rupture  of  large  vessels  due  to  previous  athe- 
romatous degeneration,  or  in  the  course  of  gangrene, 
cancer,  or  thoracic  aneurism.  It  occurs  more  frequently 
among  men  than  women,  for  the  obvious  reason  that 
they  are  more  exposed  to  the  cause.  Besides  j)rofuse 
haemoptysis  and  symptoms  of  collapse,  bubbling  rales 
of  various  kinds  would  be  heard  over  the  chest  before 
the  blood  coagulated.  If  the  patient  lived,  then  after 
coagulation  of  blood  there  would  be  signs  of  more  or 
less  consolidation.  After  absorption  of  the  clot  and  re- 
covery has  taken  place,  the  signs  would  again  become 
normal,  unless  a  cavity,  cicatrized  tissue,  or  some  other 
abnormal  condition  remained.  Generally,  however, 
the  patient  dies  before  physical  examination  can  be 
made  or  any  treatment  be  adopted. 

HEMOPTYSIS. 

Haemoptysis  is  the  expectoration  of  blood,  pure,  or 
mixed  with  other  matters,  but  always  in  quantity 
sufficient  to  be  seen  with  the  naked  eye.     In  order  to 


HEMOPTYSIS.  101 

constitute  true  haemoptysis,  the  blood  must  come  from 
the  larynx,  trachea,  bronchi,  or  pulmonary  tissue,  or, 
accordiug  to  Walshe,  from  any  part  of  the  resjjiratory 
tracts  below  the  epiglottis.  It  occurs  more  frequently 
among  men  than  women,  and  from  fifteen  to  thirty-five 
years  of  age.     It  is  rare  in  children  and  old  j^eople. 

In  general  terms,  wounds  or  other  injuries,  ulcerative 
processes,  over-distention  of  caj^illaries  from  any  cause, 
and  weakness  of  their  walls,  owing  to  perverted  nutri- 
tion, are  more  or  less  causative  of  hsemoptysis,  as  well 
as  hemorrhage  from  other  organs.  In  addition  to  these 
there  are  certain  local  causes  to  be  considered. 

Laryngeal  or  tracheal  hemorrhage  is  not  a  very  fre- 
quent source  of  haemoptysis,  nor  is  it  usually  copious. 
At  most  the  sputa  are  tinged  or  streaked  with  blood. 
It  is  due  sometimes  to  severe  catarrhal  hypersemia  (con- 
gestion), but  is  more  frequently  caused  by  ulcerative 
processes  of  some  kind,  such  as  syphilitic,  cancerous, 
or  tuberculous,  and  sometimes  it  is  due  to  the  presence 
of  aneurism. 

Bronchial  hemorrhage  is  the  most  frequent  source 
of  hsemoptysis.  Besides  ulcerative  causes,  especially 
in  connection  with  mediastinal  tumors  and  thoracic 
aneurism  and  traumatism,  the  cai)illaries  may  become 
over-distended  and  rupture  from  intense  hypereemia, 
as  in  severe  bronchitis,  mitral  obstruction  and  regur- 
gitation, or  excessive  action  of  the  heart  from  hyper- 
trophy or  stimulants.  Rupture  of  cajnllaries  from 
weakness  of  their  walls  is  seen  in  the  hemorrhagic  di- 
athesis (hsemophilia),  which  appears  to  be  hereditary, 
scurvy,  scrofula,  and  rickets,  and  in  chronic  interstitial 
nexDhritis  (cirrhotic  kidney),  with  hypertrophy  of  the 


102  PHYSICAL    DIAGNOSIS. 

left  ventricle  and  brittleness  of  the  arterioles  througli- 
ont  the  body.  It  may  also  occur,  for  the  same  reason, 
in  the  course  of  typhoid  fever,  malarial  fevers,  and  the 
exanthemata  which  sometimes  assume  a  hemorrhagic 
character. 

Profuse  haemoptysis  from  bronchial  hemorrhage  may 
also  occur  in  tuberculous  patients  before  there  are  any 
physical  signs  of  tubercle.  After  the  disease  has  be- 
come established,  it  is  usually  easy  to  account  for  the 
hemorrhage,  but,  according  to  Walshe,  "  the  very  early 
hfemoptyses  of  tubercle  remain  anatomically  unex- 
plained." It  is,  however,  due  to  fatty  degeneration  or 
tubercular  ulceration  of  the  blood-vessels. 

Vicarious  bronchial  hemorrhage  with  haemoptysis 
sometimes  takes  the  place  of  the  menses,  but  even  here 
the  women  are  probably  phthisical. 

Lastly,  pulmonary  hemorrhage  as  a  source  of  hsemop- 
tysis  is  next  in  frequency  to  bronchial.  They  are  pro- 
duced by  similar  causes  and  often  exist  together.  In 
addition  to  causes  already  mentioned,  it  occurs  to  a 
slight  extent  in  acute  lobar  pneumonia,  and  hence  the 
characteristic  rusty  colored  sputa  in  that  disease.  It 
may  be  due  to  rarefaction  of  air  during  violent  inspira- 
tory efforts  with  the  glottis  obstructed,  as  in  croup. 
In  fact,  intense  congestion  from  any  cause  may  pro- 
duce it  (see  Pulmonai-y  Congestion). 

It  may  occur  also  in  the  course  of  hydatid  disease, 
cancer,  gangrene,  abscess,  and  pulmonary  consumption 
in  any  stage.  After  cavities  are  formed  in  the  latter 
disease,  large  vessels  ramifying  on  their  walls,  or  ex- 
tending through  them,  first  become  aneurismal,  and 
then  may  rupture,  giving  rise  to  profuse  haemoptysis 


HEMOPTYSIS.  103 

which  may  speedily  prove  fatal.  According  to  Eich- 
horst,  pulmonary  hemorrhage  may  also  be  of  nervous 
origin,  and  occurs  among  the  insane,  in  chorea,  epilepsy, 
hypochondriasis,  and  in  various  cerebral  and  spinal 
diseases.  It  occurs  also  in  pulmonary  infarction  as 
well  as  diffuse  apoplexy  of  the  lungs  from  any  cause, 
as  previously  mentioned  (see  Infarction  and  Diffuse 
Apoplexy  of  the  Lungs). 

The  physical  signs  have  reference  only  to  those  cases 
where  an  appreciable  amount  of  blood  is  contained  in 
the  respiratory  tracts.  They  differ  during  the  flow  of 
blood  and  after  coagulation  has  taken  place. 

Inspection  during  the  flow  of  blood.  Besides  seeing 
the  blood  expectorated,  there  may  be  more  or  less 
dyspnoea,  increased  frequency  of  resx3iration,  and  pallor 
of  the  surface,  if  the  haemoptysis  is  profuse. 

Palpation  and  Percussion  at  this  stage  usually 
give  negative  results.  Rhonchal  fremitus,  however, 
may  be  present. 

Auscultation. — Moist  bubbling  rales  of  various  sizes 
may  be  heard  in  the  different  bronchial  tubes.  Even 
crepitant  rales  are  sometimes  heard. 

The  vocal  resonance  is  generally  unchanged.  But 
after  coagulation  has  taken  place,  all  the  physical  signs 
will  usually  be  those  of  consolidated  lung  tissue,  and 
in  proportion  to  the  amount  of  coagulated  blood  and 
the  area  involved. 

Differential  Diagnosis. — It  is  necessary  to  distin- 
guish haemoptysis  from  bleeding  from  the  mouth  and 
pharynx,  epistaxis,  and  hsematemesis. 

Careful  examination  of  the  mouth  and  pharynx  will 
readily  exclude  them  as  sources  of  the  bleeding.     The 


104  PHYSICAL    DIAGNOSIS. 

same  is  true  for  bleeding  from  the  nose.  Even  in  cases 
occurring  during  the  night  when  some  of  the  blood  is 
swallowed,  or  gets  into  the  pharynx  during  sleep,  there 
are  apt  to  be  evidences  of  nose  bleeding.  Moreover  the 
blood  hawked  up  in  these  cases  is  dark  and  mingled 
with  nasal  secretions  and  is  unattended  by  any  pre- 
vious symptoms  or  cough.  In  hasmatemesis  (vomiting 
of  blood)  the  blood  is  vomited  up,  and  is  usually  dark 
and  clotted,  and  mingled  with  food  and  acid.  In 
cancer  of  the  stomach,  however,  it  resembles  coffee 
grounds  from  being  partly  digested,  and  in  ulcer  of 
the  stomach  the  vomiting  of  fresh,  liquid  blood,  may 
be  profuse.  But  in  all  cases  hsematemesis  is  usually 
preceded  by  symptoms  referable  to  the  epigastric  re- 
gion, such  as  severe  pain  after  eating,  and  nausea.  In 
haemoptysis  the  blood  coughed  up  is  usually  bright 
red,  frothy,  pure  or  mixed  with  sputa,  is  alkaline,  and 
haemoptysis  is  usually  preceded  by  symptoms  refer- 
able to  the  chest,  such  as  a  sense  of  constriction,  pain, 
and  a  warm  tickling  sensation  behind  the  sternum.  In 
gastric  hemorrhage  also,  the  stools  may  be  black  (me- 
laena)  from  the  i)resence  in  them  of  dark  blood.  Occa- 
sionally when  gastric  hemorrhage  is  jjrof  use,  the  blood 
is  alkaline  and  bright  red,  as  in  some  cases  of  ulcer  of 
the  stomach,  and,  on  the  other  hand,  in  lia3moptysis  it 
may  sometimes  be  dark  and  clotted,  but  the  symptoms 
referable  to  the  stomach  and  chest  in  each  case  respect- 
ively, will  usually  lead  to  a  correct  diagnosis. 

The  seat  of  the  hemorrhage  in  haemoptysis  depends 
on  the  particular  cause  in  each  case.  As  bronchial  and 
pulmonary  hemorrhage  are  often  due  to  the  same  cause 
and  may  exist  together,  it  would  be  very  difficult,  if 


ECHINOCOCCI,  OR  HYDATIDS  OF  THE  LUNGS.        105 

not  impossible,  in  all  cases  to  distinguish  between  the 
two.  Bronchial  hemorrhage,  however,  is  much  more 
frequent  than  pulmonary. 

ECHINOCOCCI,   OR  HYDATIDS   OF  THE   LUNGS. 

Echinococci,  or  hydatids  of  the  lungs,  as  well  as  of 
other  organs  of  the  body,  occur  usually  where  dogs  are 
plentiful,  as  in  Iceland,  Australia  and  other  countries. 
No  locality  can  be  said  to  be  free  from  the  disease 
Avhere  there  are  dogs  and  open  water  for  drinking  pur- 
]poses,  since  it  is  through  infected  water  that  the 
disease  is  most  frequently  contracted.  Eggs  or  scolices 
of  the  taenia  echinococcus  may  also  be  inhaled,  or  car- 
ried to  the  mouth  by  the  fingers,  and  so  enter  the 
body. 

'\'Vlien  taken  into  the  stomach,  as  in  drinking  in- 
fected water,  they  are  carried  by  the  portal  circulation 
into  the  liver,  where  they  usually  locate  first,  esjDecially 
the  right  lobe.  From  thence  they  may  migrate  into 
the  lungs,  pericardium,  p)leural  cavities,  peritoneum, 
stomach,  and  intestines.  They  generally  enter  the 
lower  lobe  of  the  right  lung  from  the  liver,  directly 
through  the  diaphragm,  and  hence  the  frequency  with 
which  they  are  found  in  that  locality.  But  instead  of 
this,  they  may  also  find  their  way,  by  the  hei)atic  veins, 
into  the  inferior  vena  cava,  and  so  through  the  right 
heart  into  any  part  of  one  or  both  lungs.  When  in- 
haled they  are  more  apt  to  attack  the  upper  lobe  of 
the  right  lung,  as  I  saw  with  Drs.  Goetz  and  Riverdin,  in 
the  case  of  a  lad  eighteen  years  of  age,  in  the  County 
Hospital  in  Geneva,  Switzerland,  during  a  visit  there 
in  the  month  of  August,  1888.     This  case  will  be  re- 


106  PHYSICAL    DIAGNOSIS. 

ferred.  to  again  when  speaking  of  pleurisy  (see  Pleurisy 
with  Effusion — Diagnosis,  p.  147). 

The  physical  signs  differ  according  as  lung  tissue  is 
compressed  or  one  or  more  cysts  are  superficial  and 
extensive.  In  the  latter  case,  besides  dyspnoea,  hae- 
moptysis and  emaciation  as  the  case  jDrogresses,  there 
may  be  bulging  of  the  chest  walls  with  displacement 
of  the  heart  and  liver.  The  dullness  may  extend  across 
the  median  line,  with  diminution  or  even  absence  of  the 
resj)iratory  murmur  and  vocal  fremitus  over  the  seat 
of  dullness. 

In  other  cases,  compression  of  the  lung  may  give  in- 
creased vocal  fremitus,  bronchial  breathing  and  bron- 
cho]ohony  at  some  point.  Should  the  contents  of  the 
cyst  be  expectorated,  signs  of  a  cavity  may  result. 

Differential  Diagnosis. — Physical  signs  of  jDleurisy 
with  effusion  at  the  upper  instead  of  the  lower  part  of 
the  thorax  should  alw^ays  be  regarded  with  suspicion. 
But  a  positive  diagnosis  in  any  case  can  only  be  made 
when  a  cyst  ruptures  and  scolices  or  hooklets  are  found 
in  the  sputa.  At  the  same  time  if  a  hydatid  cyst  is 
suspected  and  it  is  sufficiently  near  the  surface,  some 
of  the  fluid  aspirated  by  means  of  the  hypodermic 
syringe  may  be  found  to  contain  scolices  and  hooklets. 

PHTHISIS. 

Phthisis  is  tuberculosis,  and  as  now  accepted  implies 
pulmonary  tuberculosis,  a  disease  caused  by  a  sjiecific 
virus,  the  germ  of  which  is  Koch's  tubercle  bacillus^ 
and  infectious  under  conditions  to  be  mentioned.  It  is 
usually  a  chronic  disease,  the  forms  of  which  may  be 
reduced  to  two  according  to  the  tissues  chiefly  involved: 
(1)  catarrhal  arid  (2)  fibroid. 


PHTHISIS.  107 

CatarrJialpMliisis  (caseous  phthisis,  tubercuhir  lob- 
ular pneumonia)  is  the  most  common  form  observed, 
and  it  usually  appears  first  at  the  top  of  the  lungs,  but 
not  always.  Beginning  in  the  bronchioles,  it  extends 
into  the  air  cells  and  along  the  air  passages.  From 
caseous  necrosis  and  softening,  cavities  result.  This 
form  occurs  usually  between  twenty  and  thirty,  and  in 
women  somewhat  earlier  than  in  men  (p.  113). 

Fibroid  phthisis  also  usually  begins  in  the  bron- 
chioles, but  extends  along  the  lymphatics  to  the  pul- 
monary interstitial  connective  tissue,  producing  shrink- 
age and  bronchiectasis  as  with  interlobular  pneumonia 
(p.  87).  It  occurs  more  frequently  in  men  and  from 
thirty  to  forty,  and  is  usually  more  chronic  in  its  course 
than  the  catarrhal  form  (p.  131). 

Phthisis  is  said  to  be  acute  when  its  progress  is  rapid. 
In  such  cases  it  may  a^^pear  to  begin  as  a  lobar  pneu- 
monia, but  its  nature  soon  becomes  apparent  (phthisis 
florida,  galloping  consumption,  tuberculous  or  scrofu- 
lous pneumonia).  When  asociated  with  extensive  he- 
patization, the  acute  form  is  termed  by  Williams,  of 
London,  acute  tuberculo-pneumonic  XDlithisis.  When 
the  larynx  is  XDrimarily  the  seat  of  tubercle,  it  is  called 
laryngeal  i)lithisis,  or  better,  tuberculous  laryngitis, 
although  primary  tuberculous  laryngitis  is  not  a  com- 
mon affection.  When  hemorrhage  is  an  early  and 
prominent  symptom  it  is  sometimes  called  hemorrhagic 
phthisis. 

Acute  miliary  (general,  disseminated)  tuberculosis  af- 
fects various  organs  and  tissues  simultaneously.  There 
is  usually  previous  tubercular  lesion  from  which  bacilli 
in  large  numbers  are  absorbed  into  the  blood  through 


108  PHYSICAL   DIAGNOSIS. 

lymi:)liatics  or  unocchided  veins.  It  usually  runs  a 
rapid  course,  and  somewhat  resembles  typhoid  fever, 
the  chest  signs  present,  if  any,  being  those  of  bronchi- 
tis with  marked  dyspnoea.  The  temperature  usually 
runs  high,  but  may  fall  below  normal.  The  disease  is 
rapidly  fatal  as  a  rule,  and  often  not  to  be  detected 
during  life.  On  post-mortem  examination,  not  only 
the  lungs,  but  the  pleurae  and  other  organs  may  be 
found  to  be  studded  with  miliary  tubercles. 

The  following  brief  summary  of  conclusions  is  based 
upon  the  transactions  of  the  Congress  for  the  Study  of 
Tuberculosis,  lield  in  Paris  during  the  month  of  July, 
1888. 

1.  True  tubercle  generally  (not  always)  contains  the 
bacillus  that  was  first  supposed  to  exist  by  Bouchard, 
of  Paris,  in  1880,  but  afterward  discovered  by  Koch, 
of  Berlin,  in  1882.  All  other  substances — products  of 
inflammation  in  connection  with  other  conditions  than 
tubercle  (caseous  for  example),  and  occurring  in  non- 
tuberculous  subjects — do  not  contain  Koch's  tubercle 
bacillus.  That  is  the  true  difference  between  tubercle 
and  such  other  products.  When  true  tubercle  does 
not  contain  the  bacillus,  it  is  because  the  latter  has 
been  liberated  and  escaped,  oAving  to  breaking  down  of 
tissue  by  pathological  process,  or  else  the  tubercle  yet 
contains  only  germs  of  undeveloped  bacilli.  True  tu- 
berculous virus,  therefore,  though  it  may  not  contain 
Koch's  tubercle  bacillus,  is,  nevertheless,  capable  of  re- 
producing itself  by  inoculation,  under  the  usual  con- 
ditions, by  reason  of  bacillary  germs.  Any  other  sub- 
stance than  tubercle  that  contains  Koch's  tubercle 
bacillus,  or  its  germs  (caseous  products,  for  example, 


PiiTiiisis.  109 

which  have  become  infected  by  the  bacillus,  or  its 
germs,  as  may  occur  in  tuberculous  subjects),  can  also 
produce  true  tuberculosis  by  inoculation.  Other  sub- 
stances, however,  aj)art  from  tuberculous  subjects,  and 
not  containing  Koch's  tubercle  bacillus  or  its  germs, 
cannot  directly  produce  true  tuberculosis. 

Koch's  tubercle  bacillus  thrives  best  at  a  temperature 
of  98""  F.  to  100°  F.,  and  is  capable  of  jDroliferation  be- 
tween 86°  F.  and  104°  F.,  although  it  may  live  far  be- 
yond these  extremes.  It  remains  virulent  in  running 
water  at  a  temperature  of  60°  F.,  for  six  weeks,  and  in 
stagnant  water,  of  the  same  temperature,  for  eighteen 
weeks ;  in  dried  sputa  for  a  month.  It  attacks  the  lungs 
by  preference,  although  no  tissue  is  exempt  from  it. 

2.  Koch's  tubercle  bacillus  is  the  cause,  not  the  re- 
sult, of  tuberculosis,  inherited  or  acquired,  however  this 
fact  may  yet  be  doubted  or  disputed  by  some.  In  case 
of  inheritance,  not  only  may  there  be  narrow  chest, 
feeble  health,  or  other  predisposition,  but  the  disease 
may  be  actually  and  directly  transmitted  to  the  ovule 
by  spermatozoa  infected  with  bacillary  germs. 

3.  Tuberculosis  is  a  contagious  disease  under  certain 
conditions,  especially  those  that  tend  to  produce  low- 
ered vitality,  such  as  overwork,  insufficient  food,  viti- 
ated atmosphere,  and  prolonged  ill  health  from  any 
cause,  and  is  transmissible  even  between  man  and  ani- 
mals by  the  digestive  tract,  as  was  first  proved  by  the 
experiments  of  Chauveau,  in  1868,  through  uncooked 
tuberculous  food,  especially  cow's  milk  and  beef.  Also 
by  the  resj)iratory  tract,  through  infected  air,  as  was 
proved  by  Yillemin  in  1869,  and  Tappeiner  in  1876-77. 
Hence  the  necessity  for  strict  sanitary  measures  as  a 


110  PHYSICAL    DIAGNOSIS. 

means  of  prophylaxis.  True  tuberculous  virus  is  also 
transmissible  by  inoculation,  by  subcutaneous  injec- 
tion, or  through  the  integument  stripped  of  its  epider- 
mis, as  was  proved  by  Yillemin  in  1869 ;  and  also  in 
the  following  ways :  By  other  mucous  membranes  than 
those  already  mentioned,  as  the  conjunctival  and  gen- 
ito-urinary;  by  dermatoses  which  destroy  the  epider- 
mis ;  through  the  sudoriparous  and  sebaceous  glands ; 
and,  finally,  through  wounded  and  absorbing  surfaces. 

4.  In  the  early  diagnosis  of  doubtful  or  suspected 
cases  of  pulmonary  tuberculosis  in  man,  Koch's  tuber- 
cle bacillus  should  be  sought  for  in  the  sputa  by  an 
expert,  as  the  general  practitioner  has  neither  the  time, 
experience,  nor  the  j)roper  instruments  for  it.  Even 
then  it  is  not  always  possible  to  find  the  bacillus  at 
first,  because  it  may  not  yet  have  been  liberated,  or 
only  its  germs  may  exist.  To  verify  it,  two  or  three 
lower  animals  (guinea-jDigs,  or  rabbits,  for  instance) 
may  be  put  under  the  necessary  devitalizing  conditions, 
inoculated  with  the  suspected  sputa,  and  killed  at 
varying  intervals  after  a  month  or  more.  If  it  is  the 
disease  in  question,  some  tubercles,  containing  Koch's 
tubercle  bacillus,  will  usually  be  found  in  various 
organs. 

5.  No  practical  means  for  destroying  Koch's  tubercle 
bacillus  in  patients  has  yet  been  discovered,  although 
various  methods  have  been  employed. "^ 

6.  The  management  of  tuberculosis  in  man  at  the 
present  time  should  therefore  be  directed  toward  two~ 

*  As  we  go  to  press  Koch  is  said  to  have  discovered  the  cure  for 
tuberculosis. 


PHTHISIS.  Ill 

objects:  (1)  Propliylaxis  in  all  its  relations  to  the  dis- 
ease, and  (2)  treatment  by  medicines  only  as  synii)toms 
arise  that  require  it.  (Report  of  R.  C.  M.  Page,  M.D., 
Delegate  from  the  New  York  Academy  of  Medicine  to 
the  Congress  held  in  Paris,  July,  1888,  for  the  Study  of 
Tuberculosis  in  Man  and  Animals.  New  York  Medi- 
cal Record,  Oct.  18th,  1888.) 

From  what  has  already  been  said  it  is  seen  that  tuber- 
culosis is  a  disease,  the  germ  of  which  is  the  bacillus 
discovered  by  Koch  in  1882,  and  that  it  manifests 
itself  in  various  ways,  most  frequently  as  pulmonary 
tuberculosis  or  phthisis.  But  instead  of  this,  or  with 
it,  sometimes  it  manifests  itself  as  acute  miliary  tuber- 
culosis, or  tubercular  peritonitis,  meningitis,  or  pleu- 
ritis,  and  the  like. 

Pleurisy  is  thought  by  some  to  be  productive  of 
phthisis.  While  it  may  be  a  cause  of  interlobular  (in- 
terstitial, chronic)  jjueumonia  from  extension  of  pleu- 
ritic inflammation,  it  cannot  be  directly  productive  of 
phthisis  unless  the  pleurisy  be  of  tuberculous  origin, 
as  may  sometimes  hai)pen.  In  by  far  the  greater 
number  of  these  cases,  however,  the  disease  begins  in 
the  lungs  and  extends  to  the  pleura,  the  affection  of 
the  latter  being  only  symptomatic  of  the  former  which 
has  been  overlooked  or  not  even  suspected.  Non- 
tuberculous  pleurisy  can  only  give  rise  to  phthisis  in- 
directly by  lowering  vitality  and  limiting  respiratory 
movements  so  as  to  render  the  patient  more  susceptible 
to  tuberculous  infection.  In  like  manner  chronic  pneu- 
monia and  bronchitis  may  act  as  predisposing  causes, 
the  latter  also  favoring  the  lodgment  of  bacilli  by 
rouo-hening  the  bronchial  mucous  membrane. 


112  PHYSICAL   DIAGNOSIS. 

The  disease  attacks  both  sexes  at  all  ages,  but  is  seen 
most  frequently  among  those  between  twenty  and 
thirty.  As  already  stated,  anything  that  tends  to 
lower  vitality  XDredisj^oses  to  it.  In  addition  to  what 
has  already  been  said  under  this  head,  may  be  men- 
tioned insufficient  light,  damiD  localities,  previous  dis- 
ease, mental  anxiety,  rapid  child-bearing,  lactation, 
venereal  excess,  menstrual  disorders,  and  the  like. 
Occupations  necessitating  inhalation  of  irritating  par- 
ticles would  not  of  themselves  produce  fibroid  phthisis, 
although  they  act  powerfully  as  predisposing  causes. 
According  to  Flint,  those  who  already  have  general 
emphysema,  or  cardiac  disease,  are  not  so  subject  to 
pulmonary  consumi:>tion  of  any  kind. 

A  much-vexed  question  has  been  the  relation  between 
scrofula,  so  called,  and  tubercle.  According  to  Flint, 
those  who  suffer  from  scrofulous  affections  of  the  cer- 
vical lymphatic  glands  are  not  liable  to  pulmonary 
tuberculosis.  "  Assuming,"  says  Flint,  "  the  scrofulous 
and  tuberculous  cachexia  to  be  the  same,  as  is  claimed 
by  some,  it  seems  to  be  exhausted  by  deposit  in  the 
glands  of  the  neck,  and  is  not  likely  to  occur  after- 
ward." The  truth  is,  there  is  no  such  thing  as  scrofula, 
but  it  is  tuberculosis  in  which  the  bacilli  are  confined 
to  the  lymphatic  system,  where  they  become  destroyed 
or  modified.  On  the  other  hand,  they  thrive  in  the 
lungs  and  proliferate  rapidly. 

In  phthisis  the  disease  usually  begins  at  the  apices, 
but  as  to  whether  the  apex  of  one  lung  is  more  fre- 
quently affected  than  the  other  is  not  a  settled  matter. 
As  in  most  cases,  however,  the  disease  is  started  by 
inhalation  of  air  containing  bacilli,  the  ajiex  of  the 


PLATE    IV. 


Tubercular  Pulmonary  Consumption.  Microscopic  Specimen 
from  Sputa  containing  (b)  Bacilli,  (a)  Alveolus,  (e  c)  Endothelioid 
Cells,  fep.  c)  Epithelial  Cells,  Lung  Tissue  stained  with  Methyliri 
Blue — Bacilli  with  Gentian  Violet. 


MOUHJID  /mo  DRAWN    BY  H.MACOONALD    M.D.  N.Y. 


CATAIIUIIAL    J'lITIIISIS,    THUEE    STAGES.  113 

right  lung  is  probably  the  one  most  often  primarily 
affected,  the  right  bronchial  tube,  as  so  often  stated, 
being  larger  than  the  left.  But  the  reasons  why  the 
apices  are  affected  primarily  appear  to  be:  (1)  injury 
to  the  vessels  here  from  imperfect  circulation  and  stag- 
nation of  blood,  exposure,  and  strain  from  coughing  or 
lifting,  giving  rise  to  exudation ;  (2)  limited  respiratory 
motion  with  imperfect  ventilation  and  non-absorption 
of  exudations — conditions  all  of  which  favor  the  lodg- 
ment of  bacilli. 

1.  CATARRHAL  PHTHISIS. 
Catarrhal  jDhthisis  (caseous  x^hthisis,  caseous  infiltra- 
tion, broncho-pneumonic  phthisis,  bronchitic  phthisis, 
tuberculous  lobular  pneumonia)  is  one  of  the  two  varie- 
ties of  chronic  phthisis.  It  may  assume  various  forms, 
but  as  commonly  met  with  is  usually  divided  into 
three  stages: 

1.  A  stage  of  incomplete  consolidation  of  lung-tissue  with  more 
or  less  localized  secondary  bronchitis,  usually  of  the  smaller 
tubes,  lobular  pneumonia,  or  circumscribed  pleurisy,  or  all  three. 

2.  A  stage  of  complete  consolidation  of  lung-tissue,  commenc- 
ing softening,  and  one  or  all  of  the  attending  complications 
mentioned. 

3.  The  breaking  down  of  tissue  and  the  formation  of  cavities. 
All  the  complications  mentioned  are  more  frequently  jDresent  in 
this  stage. 

Inspection.  First  Stage. — This  may  give  negative 
results.  Usually,  however,  even  in  this  stage,  expan- 
sion of  the  chest  over  the  affected  portion  may  not  be 
as  well  marked  as  on  the  healthy  side,  especially  on 
deep  inspiration.  There  may  also  be  some  slight  flat- 
tening over  the  affected  part,  and  when  at  the  apex,  the 
clavicle  on  the  affected  side  may  be  more  prominent 
than  the  other.     The  respiratory  movements  are  some- 


114  PHYSICAL    DIAGNOSIS. 

what  increased  in  frequency,  and  the  apex-beat  of  the 
heart  will  be  more  raj)id  than  in  health,  but  in  the  nor- 
mal position,  unless  displaced  by  some  complication. 
Though  the  appetite  is  usually  poor,  even  in  this  stage, 
emaciation  is  not  yet  usually  noticeable. 

Palpation.  First  ^tage. — The  vocal  fremitus  is  usu- 
ally exaggerated  (slightly  increased)  over  the  affected 
part,  since  the  latter  now  conducts  the  voice  sound  bet- 
ter than  in  health.  As  solidification  becomes  complete 
so  does  the  fremitus  increase,  owing  to  obliteration  of 
air-cells,  by  which  the  affected  part  becomes  a  more 
homogeneous  medium  for  the  conduction  of  sound,  in- 
stead of  refracting  it  as  in  health.  It  should  not  be 
forgotten,  however,  that  the  vocal  fremitus  is  normally 
exaggerated  under  the  patient's  right  clavicle  in  health, 
on  account  of  proximity  to  the  large  right  primitive 
bronchial  tube,  by  which  the  voice  sound  is  conveyed 
with  considerable  force  to  that  region.  The  skin  is 
usually  unnaturally  warm  and  dry.  The  apex-beat  of 
the  heart  is  felt  to  be  more  rapid  than  in  health,  as 
also  the  pulse. 

Percussion.  First  Stage.— There  is  the  quality  of 
slight  dullness  on  percussion  over  the  affected  part, 
with  consequent  slight  raise  in  the  pitch,  shortening  of 
the  duration,  and  diminution  of  the  intensity  (or 
amount)  of  the  note  in  the  sense  of  volume.  But  slight 
dullness  is  obtained  in  health  in  the  right  subclavicu- 
lar region,  on  account  of  the  right  muscles  being  thicker 
than  the  left,  and  other  reasons  already  stated  (see 
Percussion  of  the  Chest  in  Health.     Chap.  I.). 

Myoidema  (muscle  swelling)  is  a  knot  that  rises  up 
from  the  surface  of  the  chest,  in  some  cases,  after  a 


CATAKIIHAL    PHTHISIS,   FIRST   STAGE.  115 

sharp  blow  upon  the  latter  immediately  with  the  point 
of  the  finger.  It  may  be  observed  now,  but  is  more 
marked  in  tlie  later  stages,  when  emaciation  is  more 
noticeable.  It  was  first  observed  by  Stokes,  of  Dublin, 
about  1830,  but  was  so  named  by  Lawson  Tait,  of  Birm- 
ingham (Dublin  Jour.  Med.  Science,  1871,  vol.  52,  p.  316) 
It  is  obtained  over  the  pectoral  muscles  chiefly,  but 
sometimes  also  over  the  deltoid,  and  muscles  of  the 
back.  It  is  due  to  muscular  irritability,  as  may  occur 
with  emaciation  from  any  cause,  and  was  at  first 
called  by  Schiff  and  others  "  idlo-rauscular  contractil- 
ity." It  was  thought  to  be  pathognomonic  of  phthisis 
at  one  time,  even  in  the  absence  of  other  signs,  but  at 
present  it  is  regarded  as  of  little  value,  and  is  observed 
to  occur  in  other  diseases,  as  typhoid  fever,  and  dij)h- 
theria,  and  indeed  I  believe  it  may  be  obtained  in  some 
•cases  wdiere  there  is  perfect  health. 

Auscultation.  First  Stage. — The  resj)iratory  mur- 
mur over  the  affected  part  has  now  lost  its  purely  vesic- 
ular quality,  the  vesicles  or  air-cells  of  the  diseased 
part  having  been  more  or  less  obliterated  by  the  pres- 
ence of  tubercles,  causing  pressure  and  local  inflamma- 
tion. The  breathing  is  therefore  a  mixture  of  bronchial 
and  vesicular  or  broncho- vesicular,  as  Flint  termed  it. 
As  Da  Costa  says,  however,  it  is  better  to  call  it  vesic- 
ulo-bronchial,  that  being  the  order  in  which  the  two 
qualities  occur.  Inspiration  is  increased  in  intensity, 
in  the  sense  of  concentrated  amount,  being  conducted 
with  more  force  by  the  affected  tissue  than  in  health. 
It  is  less  vesicular  than  in  health,  and  slightly  raised  in 
pitch.  It  is  barely  finished,  and  hence  is  not  quite 
continuous  with  expiration.     The  more  complete  the 


116  PHYSICAL    DIAGNOSIS. 

consolidation  and  the  greater  the  area,  the  more  un- 
finished and  shorter  will  be  inspiration.  This,  as  well 
as  bronchial  breathing,  therefore,  is  said  to  be  divided. 
Expiration  is  as  long  as  or  longer  than  inspiration,  it  is 
as  intense,  the  pitch  is  as  high  or  higher,  and  the  qual- 
ity is  more  tubular.     This  vesiculo-bronchial  murmur 


Fig.  13.— Vesiculo-bronchial  Breathing. 

was  formerh^,  and  is  now,  by  some  termed  rude,  be- 
cause it  is  more  intense  than  normal.  Others  speak  of 
it  as  harsh  or  rough  breathing,  all  of  which  are  unde- 
scriptive  of  the  true  characteristics.  Either  inspiration 
or  expiration  or  both  may  be  wavy,  jerking,  cog- 
wheeled,  or  interrupted,  as  one  may  choose  to  tenn  it. 
This  variation  is  thought  by  some  to  be  due  to  the  sud- 
den passage  of  air  through  some  point  or  points  of 
stricture  in  the  bronchial  tubes,  due  to  pressure  from 
tubercles  or  obstruction  from  mucus.  But  it  is  also 
found  in  perfectly  healthy  lungs  among  some,  for  in- 
stance, who  have  j)alpitation  of  the  heart,  or  are  nerv- 
ous from  any  cause.  It  is  not  at  all  uncommon  among 
women,  men  addicted  to  the  abuse  of  alcohol  or  to- 
bacco, the  choreic,  and  other  nervous  subjects.  It  is  of 
great  importance  to  remember  that  the  normal  vesic- 
ulo-bronchial breathing  is  heard  in  the  right  subcla- 
vicular region,  owing  to  the  proximity  to  the  large 
right  bronchial  tube. 

Pectorophony  (vocal  resonance),  like  the  fremitus,  is 
exaggerated  (slightly  increased)  over  the  affected  part. 

Adventitious  sounds  are  usually  heard  over  the 
affected  part  in  the  first  stage  of  iDhthisis,  and  it  is  by 


CATARRHAL   PHTHISIS,   SECOND   STAGE.  117 

means  of  these,  chiefly,  that  we  are  enabled  to  make  an 
early  diagnosis,  esj^ecially  if  the  seat  of  the  disease  be 
at  the  right  apex.  Along  with  tubercle  there  will  be  a 
localized  capillary  bronchitis,  a  spot  of  pneumonia,  or 
perhaps  pleuritis.  For  that  reason  we  are  almost  sure 
to  hear  some  subcrepitant,  crepitant,  or  intra-pleural 
rales.  Sometimes  there  may  be  a  single  click  heard, 
during  inspiration  especially.  It  is  called  the  mucous 
click,  and  is  said  to  be  due  to  the  forcible  separation 
of  an  agglutinated  tube  or  overcoming  mucous  or  other 
obstruction  by  air  during  inspiration.  It  is  probably 
of  intra-ioleural  origin  sometimes. 

Any  of  these  localized  adventitious  sounds,  in  addi- 
tion to  the  other  physical  signs  mentioned,  and  the 
history  of  the  case,  would  render  it  almost  certain  that 
the  case  was  one  of  phthisis.  The  tubercle  bacillus 
will  rarely  be  found  in  the  sputa  at  this  early  stage, 
even  by  an  expert,  because  it  will  not  usually  have  been 
liberated,  or  only  bacillary  germs  may  yet  exist.  But 
in  case  of  doubt  the  sputa  should  be  examined  by  an 
expert  if  j)ossible. 

Regarding  the  early  diagnosis  of  the  disease,  it  is 
seen  from  the  physical  signs  presented,  that  it  is  more 
readily  made  when  the  disease  affects  the  left  apex, 
since  all  of  the  early  iDhysical  signs,  except  the  local- 
ized adventitious  ones,  already  exist  in  the  patient's 
right  subclavicular  region  in  health.  * 

Second  Stage. — We  have  now  to  deal  with  complete 
solidification  of  lung  tissue  of  variable  extent,  com- 
mencing softening,  and  local  complications  (p.  113). 

*  See  also  Hwrnoptysis,  p.  102.  Unless  caused  by  heart  disease 
or  injury,  it  is  probably  due  to  phthisis  (Flint). 


118 


PHYSICAL    DIAGNOSIS. 


Inspection.  Second  Stage. — The  ex2:)ansion  of  the 
chest  walls  over  the  affected  part  is  more  markedly 
dhninished  on  inspiration  than  in  the  hrst  stage,  and 
the  difference  between  the  respiratory  movements  of 
the  unaffected  and  diseased  sides  is  more  noticeable. 
Flattening  over  the  affected  portion,  dne  to  retraction 
of  the  diseased  lung  tissue,  is  usually  noticeable  in  this 
stage.  If  it  occurs  at  the  apex,  the  clavicle  usually 
projects  and  is  noticeably  prominent.  Respiratory 
movements  are  increased  in  frequency  and  rather  shal- 
low, and  the  ajDex-beat  of  the  heart  is  usually  quite 
visible,  owing  to  emaciation,  which  now  generally  be- 
comes noticeable.  The  apex-beat  of  the  heart  may  be 
in  the  normal  position,  but  is  not  infrequently  displaced 
by  traction  due  to  pleuro-pericardial  adhesion. 

Palpation.  Second  Stage. — The  vocal  fremitus  is 
usually  noticeably  increased  on  account  of  the  better 
conducting  power  of  the  consolidated  lung  tissue.  If, 
however,  a  large-sized  bronchial  tube  leading  to  the 
affected  part  becomes  obstructed,  so  that  it  ceases  to 
convey  the  voice  sound,  the  fremitus  may  be  dimin- 
ished, or  even  absent.  Upon  coughing  and  removing 
the  plug,  the  fremitus  at  once  returns.  Thickened 
pleura  or  effusion  intervening,  would  also  cause  the 
fremitus  to  be  diminished  or  absent.  The  apex-beat  of 
the  heart  may  be  felt  to  be  abnormally  frequent  and 
feeble,  as  also  the  radial  pulse.  The  surface  of  the 
body  is  usually  felt  to  be  dry  and  unnaturally  warm. 

Percussion.  Second  Stage. — Dullness  on  percussion 
is  the  rule,  and  this  quality  will  be  marked  in  propor- 
tion to  the  extent  of  consolidation.  The  more  marked 
the  dullness,  the  higher  will  be  the  pitch,  the  shorter 


CATAKRITAL   PHTHISIS,   SEOOXD    STAGi:.  119 

the  duration,  and  the  less  the  intensity  Of  the  percus- 
sion note,  in  the  sense  of  volume.  It  happens,  how- 
ever, once  in  a  great  while,  that  Skodaic  resonance 
(tympanicity  in  connection  with  solidification  or  effu- 
sion) is  obtained.  This  requires  rather  forcible  percus- 
sion over  solidification  near  a  large  bronchial  tube,  the 
trachea,  an  empty  stomach  or  transverse  colon,  where 
the  force  of  the  percussion  blow  extends  to  them  from 
the  solidified  tissue,  which  acts  on  the  j)rinciple  of  a 
solid  pleximeter,  like  the  finger,  or  other  solid  percus- 
sion medium,  and  is  consequently  attended  with  a  feel- 
ing of  resistance.  Even  cracked-pot  resonance,  due  to 
the  concussion  of  air  in  such  localities,  is  sometimes, 
though  rarely,  obtained.  Over  the  unaffected  j)arts  the 
percussion  resonance  may  be  exaggerated,  owing  to  the 
presence  of  a  certain  amount  of  vicarious  emphysema, 
which,  however,  never  becomes  marked,  as  the  volume 
of  blood  becomes  much  diminished  in  this  wasting  dis- 
ease. 

Myoidema  is  more  noticeable  in  this  stage  than  the 
first. 

Auscultation. — The  breathing  over  the  consolidated 
lung  tissue  now  becomes  bronchial,  all  vesicular  quality 
having  disappeared  with  the  air-cells.  Both  inspiration 
and  expiration  are  tubular  in  quality  and  high  pitched, 
expiration  being  the  higher.  Expiration  is  also  as  long- 
as  inspiration,  or  longer,  and  the  two  are  separated,  or 
divided,  by  inspiration  being  unfinished.  This  respira- 
tory murmur  as  a  whole  is  more  intense  than  normal 
in  the  sense  of  concentrated  amount,  and  expiration  is 
more  intense  than  inspiration.  Both  are  somewhat 
short  owing  to  the  shallow  breathing. 


120  PHYSICAL    DIAGNOSIS. 

Pectorophony  (vocal  resonance)  is  usually  markedly 
increased  over  the  consolidated  part,  and  becomes 
bronchophony  (bronchial  voice).  Should  the  speech 
(articulate  words)  be  heard  also,  it  might  be  called 
bronchiloquy  (instead  of  pectoriloquy,  which  also  ap- 
plies to  cavities).  The  whispered  voice  would  give 
whispering  bronchophony  or  whispering  bronchiloquy, 
as  the  case  might  be.  Should  a  large  tube  leading 
to  the  part  be  obstructed,  or  there  exist  thickened 
pleura  or  effusion,  the  breath  and  voice  sounds  would 
be  diminished  or  absent,  like  the  fremitus  under  the 
same  conditions.  As  some  parts  of  the  diseased  lung 
will  probably  be  in  the  first  stage,  or  incomplete  con- 
solidation, the  physical  signs  belonging  to  that  stage 
may  be  looked  for  about  the  periphery  of  the  seat  of 
complete  consolidation.  Or  both  lungs  may  be  affected 
with  different  stages.  Localized  adventitious  sounds 
are  also  heard  about  the  affected  part  in  this  stage. 
They  are  more  marked  usually  than  in  the  first  stage, 
and  consist  of  bronchial  moist  rales  of  various  kinds, 
and  sometimes  intra-pleural  rales.  The  crej^itant  rale, 
if  present,  would  usually  be  obscured  by  other  louder 
rales.  Owing  to  commencing  softening  and  breaking 
down  of  lung  tissue,  and  perhaps  pleuritic  complica- 
tions, certain  crackling  and  crumpling  rales,  called  in- 
determinate, may  be  heard  sometimes. 

Third  Stage. — In  this  stage,  cavities  are  formed. 
But  in  addition  to  cavities,  there  may  be  portions  of 
lung  tissue  yet  in  conditions  of  complete  and  incom- 
plete solidification,  so  that  we  may  have  all  three  stages 
present  at  once.  Besides  these,  the  usual  secondary 
inflammations  also  exist,  such  as  localized  bronchitis 


CATARRHAL   PHTHISIS,   THIRD   STAGE.  121 

and  pleuritis.  We  therefore  usually  have  a  compli- 
cated pathological  condition  to  deal  with,  and  hence, 
although  rules  usually  hold  good,  we  are  not  to  be 
surj)rised  at  variations  and  exceptions. 

Inspection.  Third  Stage. — The  conditions  already 
observed  in  the  second  stage  will  be  jpresent,  but  usu- 
ally to  a  more  marked  degree.  There  are  emaciation, 
rai^id  and  shallow  respiration,  usually  marked  depres- 
sion or  flattening  of  the  chest  walls  over  the  affected 
part,  diminution  of  respiratory  movements,  especially 
on  the  affected  side,  and  prominence  of  the  superficial 
veins.  When  the  ajjex  is  the  seat  of  the  disease,  the 
supra-  and  infra-clavicular  spaces  are  markedly  de- 
pressed, as  a  rule,  with  corresponding  prominence  of 
the  clavicle.  Why  are  the  superficial  veins  usually  so 
prominent?  Not  so  much  on  account  of  obstruction 
in  the  pulmonary  circulation,  because,  as  already  stated, 
the  volume  of  the  blood  in  this  wasting  disease  is  much 
diminished,  nor  is  the  obstruction  to  the  pulmonary 
circulation  so  great  as  it  is  in  general  hypertrophous 
(large-lunged)  emphysema.  Yet  in  the  latter  disease 
the  superficial  veins  are  not  so  prominent  as  in  the  third 
or  even  second,  stage  of  i)ulmonary  consumption.  The 
true  reason  seems  to  be,  that  in  consumption,  as  ema- 
ciation progresses,  the  vessels  become  more  and  more 
prominent,  owing  to  the  absorption  of  the  fat  around 
them.  The  impulse  of  the  heart,  which  beats  rapidly, 
is  usually  visible  by  reason  of  emaciation  of  the  chest 
walls.  The  apex-beat  may  be  in  the  normal  position,  but 
it  is  not  unfrequently  displaced,  sometimes  markedly, 
not  usually  from  pressure,  however,  but  from  traction, 
due  to  pleuro-pericardial  adhesion  and  retraction  of 


1^^  PHYSICAL    DIAGNOSIS. 

the  lung.  This  is  especially  the  case  when  the  left 
lung  is  affected.  Walshe  mentions  a  case  where  the 
apex-beat  was,  found  under  the  left  clavicle.  It  may 
be  in  either  axillary  line. 

Occasionally  insj^ection  yields  almost  negative  results, 
even  in  this  stage,  the  disease  having  become  tempora- 
rily arrested,  and  the  patient  improved  in  general  health 
for  the  time  being.     (See  HcB^uoptysis,  j).  102.) 

Palpation.  Third  Stage. — The  vocal  fremitus  is  in- 
creased over  the  affected  part,  as  a  rule,  owing  to  the 
consolidated  lung  tissue  near  the  ca\dty.  But  in  rare 
instances  the  increase  may  be  due  to  re-enforcement  of 
the  voice  by  echo  in  the  cavity,  a  phenomenon  of  tlie 
consonance  of  sounds.  All  the  conditions  necessary 
for  this,  however,  are  rarely  present  at  the  same  time. 
Sometimes,  instead  of  being  increased,  the  fremitus  may 
be  diminished,  or  even  absent,  for  reasons  alreadj^  enu- 
merated, such  as  obstruction  in  a  large  bronchial  tube 
leading  to  the  affected  part,  thickened  jDleura,  effusion, 
or  intervening  healthy  lung  tissue,  in  case  of  a  very 
small,  deep-seated  cavity.  Rlionchal  fremitus  due  to 
gurgles,  or  other  adventitious  sounds,  is  sometimes  felt, 
the  thinness  of  the  chest  walls,  due  to  emaciation,  fav- 
oring its  production.  The  apex- beat  of  the  heart  is 
usually  felt,  though  feeble  and  rapid.  The  skhi  is 
usually  hot  and  dry,  and  the  radial  pulse,  like  the 
heart,  of  course,  frequent  and  feeble. 

Percussion.  TJiird  Stage. — Dullness  on  percussion 
is  the  rule,  especially  gentle  percussion,  the  consolida- 
tion around  the  cavity  which  contains  more  or  less  fluid 
generally,  and  the  (condition  of  the  pleura  being  favor- 
able for  its  production.     There  are,  however,  exceptions. 


CATARRHAL    PHTHISIS,   THIRD   STAGE.  123 

(1)  Cracked-pot  resonance  is  sometimes  obtained. 
It  is  not  known  why  it  was  ever  termed  cracked-X)ot, 
for  it  does  not  sound  like  percussing  a  cracked  pot. 
The  sound  is  in  most  cases  due  to  the  sudden  forcing 
of  air  out  of  a  cavity  through  a  somewhat  small  ox)en- 
ing  communicating  with  a  bronchial  tube.  The  pa- 
tient's mouth  should  be  open,  otherwise  the  air  will 
not  be  driven  out  with  sufficient  force  to  produce  th& 
sound.  It  requires  a  cavity,  superficially  located,  at 
the  upper  part  of  the  thorax,  with  tense  but  yielding 
walls,  and  a  sharp  percussion  blow.  It  is  best  obtained 
in  emaciated  women,  as  their  chest  walls  are  more 
yielding  than  those  of  men.  The  sound  is  exactly  imi- 
tated, not  by  striking  a  cracked  pot,  but  by  clasping 
the  two  hands  together,  so  that  the  palms  form  a  cav- 
ity, and  striking  the  back  of  one  hand  or  the  other  on 
the  knee  wdth  considerable  force.  Children  do  this  to 
imitate  the  sound  of  money  in  their  hands,  and  for 
this  reason  it  is  sometimes  called  the  money  chink  res- 
onance. But  as  it  sounds  very  little  more  like  the 
chink  of  money  than  it  does  like  striking  a  cracked 
pot,  and  as  the  latter  has  the  sanction  of  age  as  well  as 
the  name  of  Laennec  associated  Avith  it,  there  ajopears  to 
be  no  good  reason  as  yet  for  changing  it.  Instead  of 
being  caused  by  the  sudden  escape  of  air  from  a  ca\dty, 
it  appears,  in  rare  instances,  to  be  due  to  concussion  of 
air  in  some  hollow  viscus.  Cracked-pot  resonance  is 
not  constant,  as  the  conditions  for  its  production  ra'p- 
idly  change,  such  as  plu'gging  of  the  opening  with 
mucus,  filling  of  the  cavity  with  fluid,  and  so  on.  In  the 
first  case  coughing  may  dislodge  the  plug,  and  the 
sound  will  reappear. 


124  PHYSICAL    DIAGNOSIS. 

(2)  Tympanitic  resonance  (drum  sound)  may  be  ob- 
tained by  percussing  rather  forcibly  over  a  large  closed 
cavity  filled  with  air,  and  having  tense  and  rather  un- 
yielding walls.  The  pitch  and  other  properties  of  the 
note  will  vary  with  the  size  of  the  cavity  and  the  ten- 
sion of  its  walls. 

(3)  Amj)horic  resonance  (jug  sound)  is  obtained  by 
percussing,  rather  forcibly,  over  a  cavity  situated  super- 
ficially at  the  upper  part  of  the  thorax,  and  having  hard, 
smooth,  and  unyielding  walls,  empty  or  nearly  so,  and 
communicating  freely  with  a  bronchial  tube — in  other 
words  a  jug-like  cavity  (latin  word  amphora,  signifying 
a  jug,  jar,  or  bottle)  which  acts  as  a  resonant  chamber. 
This  amphoric  percussion  resonance  may  also  be  called 
metallic,  the  former  having  reference  to  the  shape  of 
the  cavity,  the  latter  to  the  metallic  quality  of  the 
sound.  In  order  to  produce  it  the  patient's  mouth 
should  be  open  during  percussion,  otherwise  the  sound 
would  not  be  produced  any  more  than  by  striking  an 
empty  jug  with  its  mouth  tightly  corked.  It  is  imi- 
tated exactly  by  percussing  over  the  buccal  cavity  with 
the  cheeks  and  lips  tense,  and  the  mouth  partly  open. 
The  pitch  varies  in  different  cases,  owing  to  different 
causes,  as  already  explained,  but  the  quality  remains 
the  same. 

Gairdner  and  Finlayson  found  that  over  such  cavi- 
ties, and  especially  in  pneumo-hydrothorax,  a  marked 
amphoric  or  metallic  resonance  is  i^roduced  by  means 
of  percussing  with  one  coin  on  another  coin  (fifty-cent 
piece  for  instance),  as  a  pleximeter,  anteriorly,  while 
the  auscultator  listened  i)osteriorly — the  so-called  bell- 


CATARRHAL   PHTHISIS,   THIRD   STAGE.  125 

metal  test.     These  cavities  are  usually  situated  high 
up  toward  the  clavicle. 

(4)  Flatness  on  percussion  may  be  obtained  over  a 
large  superficial  cavity  filled  with  fluid. 

(5)  Normal  resonance  may  be  obtained  on  gentle 
percussion  over  a  deex^-seated  small  cavity,  if  healthy 
lung  tissue  intervene.  If  the  examination  be  made 
posteriorly  and  laterally,  however,  as  well  as  in  front, 
the  cavity  will  usually  be  found. 

Myoidema,  as  already  described,  is  usually  notice- 
able in  this  stage,  and  especially  on  the  front  of  the 
chest.  For  producing  it,  a  sharp  blow,  delivered  di- 
rectly with  the  point  of  the  finger,  is  required.  It  is 
of  little  value  as  a  physical  sign. 

Auscultation.  Tldrd  Stage. — As  a  rule,  cavernous 
breathing  is  heard  over  the  cavity.     That  is,  the  respi- 


FiG.  14. — Diagram  Showing  Cavernous  Breathing. 

ratory  murmur  is  blowing  in  quality  both  on  inspira- 
tion and  expiration,  giving  the  idea,  as  Flint  correctly 
states,  of  air  passing  in  and  out  of  a  hollow  space.  The 
pitch  is  usually  lower  than  normal,  expiration  being 
lower,  and  as  long  as,  or  longer,  than  inspiration,  and 
the  two  continuous.  But  the  pitch,  of  course,  varies 
with  the  size  of  the  cavity,  the  tension  of  its  walls,  and 
so  on.  A  large  cavity,  other  things  equal,  would  give 
a  lower-ijitched  cavernous  respiratory  murmur  than  a 
small  one.     Exceptions  to  this  general  rule  are:  (1)  it 


12Q  PHYSICAL   DIAGNOSIS. 

may  be  cavemo-broncliial.  Here  we  have  a  mixture, 
in  various  proportions,  of  cavernous  and  bronchial 
breathing,  owing  to  the  presence  of  a  cavity,  perhaps 
rather  small,  and  a  good  deal  of  consolidated  lung  tis- 
sue at  the  same  time.  Flint  was  the  first  to  observe  this 
variety  of  abnormal  respiratory  murmur,  and  termed 
it  broncho-cavernous.  That  it  does  exist  in  rare  in- 
stances cannot  be  denied.  But  in  the  few  cases  where 
I  have  noticed  it,  the  bronchial  element  came  last,  so 
that  I  have  usually  described  it  as  caverno-bronchial 
breathing.  (2)  Amphoric  respiration,  or  jug  breathing, 
is  the  respiratory  murmur  heard  over  a  jug-shaped  cav- 
ity, and  sounds  like  blowing  across,  or  into,  the  mouth 
of  an  empty  jug  or  bottle.  The  cavity  must  have  hard, 
smooth  walls,  and  a  large  mouth,  and  be  empty  or  con- 
tain but  little  Huid.  Amphoric  breathing  is  heard  over 
the  same  kind  of  a  cavity  that  yields  amphoric  reso- 
nance on  percussion,  although  the  two  may  not  always 
exist  at  the  same  time,  in  any  given  case. 

The  Vocal  Resonance  is  best  appreciated  when  the 
patient  whispers.  As  a  rule,  cavernous  whisper  (whis- 
pering cavernophony)  is  heard  over  a  cavity.  That  is, 
a  whisjoer  of  l:)lowing  quality,  and  rather  low  pitch, 
differing  in  the  latter  respect  from  bronchial  whisper, 
which  must  be  high  x>itched,  as  we  have  seen.  The 
pitch,  usually  low,  varies,  however,  with  the  size  of  the 
cavity,  the  amount  of  solidified  tissue,  and  so  on. 

Fectoriloqwj. — In  some  cases,  instead  of  cavernous 
whisper,  the  articulate  words  may  be  heard,  and  then 
it  is  usually  called  whisj^ering  pectoriloquy.  Now 
pectoriloquy  means  literally  chest  speech,  and  was 
first  applied  by  Laennec  to  the  vocal  resonance  heard 


CATAKIIIIAL   PHTHISIS,   THIRD   STAGE.  127 

over  cavities  wlien  the  articulate  words  were  heard. 
Not  that  one  is  able  to  carry  on  a  conversation  with  a 
patient  through  a  cavity,  but  when  only  a  distinct 
syllable  or  two  may  be  heard  in  some  simj^le  X)hrase. 
But  pectoriloquy  in  the  same  sense  is  sometimes  heard 
over  consolidated  lung  tissue,  or  even  in  health,  as  well 
as  over  a  cavity.  Pectoriloquy,  therefore,  is  a  general 
term  for  exiDressing  a  class  of  vocal  resonance,  of  which 
there  are  several  varieties.  Bronchiloquy  may  there- 
fore be  used,  it  seems  to  me,  to  express  that  variety  of 
pectoriloquy  sometimes  heard  over  consolidated  lung 
tissue,  and  caverniloquy  when  heard  over  a  cavity.  In- 
deed, Guttmann  maintains  that  bronchophony  and  pec- 
toriloquy are  practically  identical.  So  they  are,  if  we 
mean  that  it  is  possible  sometimes  to  obtain  bron- 
chial x)ectoriloquy.  But  bronchophony  and  bronchilo- 
quy are  both  necessarily  high  x^itched,  as  we  have  seen 
(Lobar  Pneumonia,  second  stage),  whereas  Flint's  whis- 
pering pectoriloquy  (caverniloquy),  as  well  as  cavern- 
ous whisper  (whispering  cavernophony)  and  cavernous 
breathing,  are  usually  low  pitched  and  blowing  in  qual- 
ity, instead  of  being  tubular.  AmphoroxDhony  and  am- 
phoriloquy  (amphoric  voice  and  speech),  whispered  or 
otherwise,  are  sometimes  heard  over  a  cavity,  and 
sound  like  speaking  out  loud,  or  whispering,  into  the 
mouth  of  an  empty  jug  or  bottle.  Amx)horic  echo  is 
simply  the  reverberation  of  the  voice,  cough,  or  breath 
sound,  in  such  a  cavity.  The  same  sort  of  cavity  is  re- 
quired for  amphorophony  or  amx3horiloquy  as  in  the 
case  of  amphoric  resonance  on  x^ercussion,  amphoric 
resxDiration,  and  metallic  or  amphoric  tinkle. 
^gox3hony  (goat's  voice)  may  also  be  heard  in  some 


128  PHYSICAL    DIAGNOSIS. 

rare  cases,  but  this  will  be  fully  considered  when 
speaking  of  pleurisy.  It  is  nothing  more  than  distant, 
tremulous  bronchophony ;  distant  on  account  of  some 
intervening  medium,  and  tremulous  from  the  presence 
of  fluid  thrown  into  vibration  by  the  voice.  Should 
the  articulate  words  be  heard,  it  would  constitute  what 
may  be  termed  tremulous  bronchiloquy. 

Adventitous  Sounds.  Third  Stage. — As  a  rule  gur- 
gles are  heard.  These  are  coarse,  bubbling  rales,  made 
in  the  cavity,  more  particularly  on  inspiration,  since 
the  air  enters  the  cavity  with  more  force  than  it  leaves 
it.  For  this  reason  the  fluid  in  the  cavity  is  stirred 
up  more  on  inspiration  than  expiration.  If  the  cavity 
be  small,  the  gurgles  may  be  fine.  They  therefore 
vary  with  the  size  of  the  cavity  and  the  amount 
and  consistency  of  the  contained  fluid.  Their  pitch 
also  depends  upon  the  amount  of  solidified  tissue, 
which  condition,  as  already  stated,  causes  them  to  be 
raised  in  pitch.  Whenever  rales  are  mentioned  as 
being  gurgles,  however,  it  is  understood  that  a  cavity 
is  present.  Metallic  tinkle  is  sometimes  heard.  Laen- 
nec  compared  this  sound  to  the  dropping  of  water 
from  a  height  into  a  metallic  basin,  and  termed  it  me- 
tallic tinkle.  It  is  also  compared,  by  some,  to  the 
dropping  of  a  pin  into  an  empty  bottle.  But  the  idea 
of  dropping  anything  is  wrong,  since  metallic  tinkle  is 
probably  never,  in  any  case,  produced  by  the  droj)- 
ping  of  anything.  In  the  first  place,  the  fluid  in  a  cav- 
ity is  generally  slimy,  and  will  slide  down  the  walls 
of  a  cavity  rather  than  drip  off.  In  the  second  place, 
the  cavity  is  too  small  to  hear  fluid  drop  from  the 
vault  into  fluid  underneath,  even  if  it  did  drop  instead 


PLATE   V. 


Phthisis    Pulmonalis;    Third    Stage,   showing  Cavity  with   Gurgles, 
Upper  Lobe  of  Right  Lung. 


3Y   H.MACDONALO     M.D.    N .Y. 


CATAintllAL    PHTHISIS,    THIKD    STAGE.  129 

of  sliding.  But  this  distance  would  further  be  dimin- 
ished by  the  tenacity  of  the  fluid,  which  would  allow 
it  to  string  down  part  of  the  way  before  it  broke  ofi'. 
This  dripping  theory,  therefore,  it  seems  to  me,  must 
be  abandoned,  especially  in  so  small  a  cavity  as  that 
usually  found  in  the  lungs.  It  is,  in  fact,  produced  by 
the  bursting  of  bubbles  of  a  small  amount  of  viscid 
fluid  in  a  cavity  containing  air,  and  which  is  a  resonant 
chamber,  the  same  in  which  we  get  amphoric  breath- 
ing and  amphoric  voice.  Metallic  tinkle  is  usually 
heard  most  distinctly  on  inspiration.  It  may  be  heard 
while  the  patient  holds  the  breath,  if  a  bubble  previ- 
ously formed  now  bursts.  Not  all  the  bubbles  will 
produce  metallic  tinkle,  but  only  those  that  burst  with 
a  sound  in  consonance  with  the  echo  of  the  cavity. 
Metallic  tinkle,  in  other  words,  is  purely  a  phenomenon 
of  the  consonance  of  sounds.  It  is  not  constant,  but 
apjDears  and  disappears  in  the  same  patient,  according 
to  the  conditions  necessary  for  its  production.  It  is 
simi)ly  the  occasional  musical  echo  of  some  adventi- 
tious sound  (a  gurgle,  usually)  in  a  reverberating 
cavity  possessing  the  qualities  of  amphoricity. 

Bronchial  rales  of  various  kinds  are  usually  present 
also,  owing  to  the  localized  secondary  bronchitis.  They 
are  usually  of  the  moist  class,  and  may  be  subcrepitant, 
submucous,  or  mucous.  The  subcrepitant  and  submu- 
cous are  most  common.  Intra-pleural  rales  and  friction 
sounds  may  also  be  present.  In  addition  to  these  there 
may  be,  and  often  are,  indeterminate  rales ;  that  is  to 
say,  certain  crackling  and  crumpling  adventitious 
sounds,  partly  dry  and  partly  moist,  and  due  to  the 

breaking  down  of  tissue.     The  crex)itant  rales,  if  pres- 
9 


130  PHYSICAL    DIAGNOSIS. 

ent,  would  probably  be  obscured  by  other  and  louder 
sounds. 

Differential  Diagnosis. — This  rests  chiefly  upon 
the  physical  signs  of  more  or  less  consolidated  luno; 
tissue  and  cavities,  with  secondary  local  inflammation, 
affecting  the  upper  part  of  the  lungs  preferably.  Bron- 
chitis is  a  general,  bilateral  disease  and  gives  no  signs 
of  solidification.  Cancer  of  the  lungs  does  this,  but  the 
dullness  often  extends  across  the  median  line,  owing  to 
co-incident  enlargement  of  mediastinal  tumors,  and  the 
sputa  are  currant  jelly.  There  is  also  the  want  of  hec- 
tic fever  in  cancer.  Old  pleurisy,  with  effusions,  may 
be  mistaken  for  phthisis,  especially  if  the  examination 
be  confined  to  the  apices  of  the  lungs.  But  flatness  on 
percussion,  changing  with  position  of  the  i)atient,  due 
to  effusion,  will  be  found  at  the  lower  part  of  the 
thorax  in  pleurisy.  Absence  of  respiratory  murmur 
over  the  seat  of  disease,  as  well  as  other  signs  of  effu- 
sion, will  also  be  noticed  (see  Pleurisy).  In  cases  of 
dou])t  the  hypodermic  syringe  may  be  used.  Only 
the  first  stage  of  phthisis  offers  room  for  doubt  about 
the  diagnosis  as  a  rule.  Then  the  signs  of  incom- 
plete consolidation,  so  fully  described,  together  with 
any  of  the  localized  adventitious  sounds  will  usually 
lead  to  a  correct  conclusion.  The  discovery  of  the 
bacillus  under  the  microscope  would  be  conclusive, 
but  the  general  practitioner  need  not  expect  to  be  able 
to  do  this,  since  he  has  generally  neither  the  time,  the 
proper  instruments,  nor  the  experience. 


FIBROID    1>IITJ1ISIS.  131 


2.  FIBROID   PHTHISIS. 

Inspection. — There  is  retraction  over  the  affected 
part,  which  may  be  at  the  upper  region  of  the  thorax 
on  the  riglit  side,  for  reasons  already  mentioned.  The 
shoulder  is  usually  lowered  on  the  affected  side,  but 
not  so  much  as  in  pleurisy  with  retraction,  and  the 
respiratory  movements  on  that  side  are  diminished  or 
even  absent,  especially  if  pleuritic  adhesions  be  pres- 
ent also,  as  is  often  the  case.  If  the  other  lung  be  un- 
affected it  becomes  more  or  less  enlarged,  as  also 
healthy  portions  of  the  affected  lung,  from  vicarious 
emphysema.  The  apex  beat  of  the  heart  is  often  dis- 
placed, sometimes  greatly  so.  When  the  right  lung 
is  affected,  the  apex  beat  of  the  heart  may  sometimes 
be  found  in  the  right  axilla.  This  is  due  to  great 
shrinkage  of  the  right  lung  and  emphysematous  en- 
largement of  the  left,  and  often  pleuro-pericardial  ad- 
hesions add  to  it  by  traction.  Should  the  left  lung  be 
affected,  the  apex  beat  may  be  found  displaced  as  far 
as  the  left  axillary  line.  The  shrinkage  of  the  thorax 
is  usually  horizontal,  with  decrease  in  the  antero-x)os- 
terior  as  well  as  other  horizontal  diameters.  But  it 
also  sometimes  settles  down,  especially  the  upper  part, 
with  decrease  of  vertical  diameter.  Tn  these  cases  the 
apex  of  the  heart,  if  not  otherwise  displaced,  will  be 
found  between  the  fourth  and  fifth  ribs  instead  of  the 
iiftli  and  sixth.  The  intercostal  spaces  are  sometimes 
much  narrowed. 

Palpation. — The  vocal  fremitus  is  increased  over  the 
indurated  tissue,  unless  there  be  obstruction  in  the 


132  PHYSICAL   DIAGNOSIS. 

tubes  from  stricture  or  other  cause,  or  interruption  due 
to  thickened  i^leura,  when  it  may  be  diminished  or 
even  absent.  Tlie  fremitus,  therefore,  thougli  increased 
usually  in  proportion  to  the  consolidation,  may  vary 
for  different  cases.  The  apex  beat  may  be  felt  out  of 
its  normal  position  or  not,  according  as  the  heart  is 
disi)laced  or  not. 

Percussion. — There  is  usually  marked  dulness  on 
percussion  over  the  indurated  lung  and  exaggerated 
resonance  over  the  emphysematous  portions.  OAving 
to  induration  of  lung-tissue,  narrowing  of  intercostal 
spaces,  and  hardening  of  the  ribs,  the  dulness  is  some- 
times termed  wooden,  and  there  is  great  feeling  of  re- 
sistance to  the  finger  on  i)alx)atory  percussion,  as  Piorry 
first  noticed.  Hence,  as  often  before  remarked,  one  of 
the  advantages  of  joalpatory  percussion  over  all  other 
methods.  Sometimes,  if  there  be  a  large  bronchiectatic 
cavity,  tympanitic,  cracked-pot,  or  other  resonance  indi- 
cative of  a  cavity  may  be  obtained  (pp.  123-125).  The 
line  of  hepatic  dullness  will  be  unusually  high  uj)  if 
the  vertical  diameter  of  the  thorax  be  much  shortened 
(pp.  136,  148). 

Auscultation. — Bronchial  breathing  and  broncho- 
phony will  be  heard  over  the  contracted  lung  unless 
convection  of  the  sounds  of  the  respiratory  murmur 
and  voice  by  the  broncliial  tubes  into  the  part  be  ob- 
structed by  stricture  of  the  bronchi,  or  i)lugging  of 
them  with  viscid  mucus,  or  other  cause.  Or  else  there 
niay  be  interruption  of  these  sounds  from  thickened 
pleura.  In  either  ca se  the  respiratory  murmur  and  whis- 
j)ered  voice  will  be  weak  or  suppressed  over  the  corre- 
sponding area,  but  the  voice,  if  uttered  loud  enough,  will 


FIBKOID   PHTHISIS.  I'SS 

surely  be  heard,  though  the  resulting  bronchophony 
may  be  distant  or  weak.  Should  bronchiectatic  cavity 
be  present,  as  generally  occurs  in  the  course  of  the  dis- 
ease, the  signs  would  indicate  it  as  already  described 
(p]3.  125-129).  No  cardiac  murmur,  unless  it  already 
exists,  necessarily  accompanies  displacement  of  the 
heart.  Owing  to  obstruction  to  the  pulmonary  circu- 
lation the  right  ventricle  becomes  somewhat  enlarged 
with  accentuation  of  the  second  sound  over  the  pul- 
monary (second  left)  interspace  (pp.  188,  189).  Owing 
to  diminution  of  the  volume  of  blood  in  this  wasting 
disease,  however,  these  signs  will  not  be  so  well  marked 
as  in  general  large-lunged  emphysema,  where  there 
is  not  only  marked  obstruction  to  the  pulmonary  cir- 
culation, but  also  a  full  volume  of  blood  not  infre- 
quently, to  be  driven  through  the  lungs. 

Differential  Diagnosis. — Unless  this  disease  affects 
both  lungs  it  may  be  impossible  to  distinguish  it  from 
chronic  (interlobular,  interstitial)  pneumonia,  which  is 
nearly  always  unilateral.  In  the  pneumonia,  patients 
do  not  have  so  much  fever,  retain  more  strength,  and 
do  not  become  so  rapidly  and  markedly  emaciated. 
Moreover,  they  do  not  suffer  from  the  hoarseness  and 
diarrhoea  due  to  tubercular  disease  of  the  larynx  and 
intestines  that  frequently  occur  in  fibroid  phthisis. 
The  tubercle  bacillus  is  not  so  abundant  in  fibroid 
phthisis  as  in  the  catarrhal  form,  and  its  discovery, 
though  decisive,  is  often  difficult  and  even  impos- 
sible. Fibroid  phthisis  is  said  to  affect  the  upper 
lobes  by  preference,  while  the  pneumonia  is  usually 
basic. 

Pleurisy  with  retraction  may  be  difficult  to  differen- 


134  PHYSICAL   DIAGNOSIS. 

tiate.  Indeed,  both  are  not  infrequently  j)resent,  so  that 
by  shrinkage  of  the  puhnonary  interstitial  connective 
tissue  and  compression  by  the  contracting  and  enor- 
mously-thickened j)leura,  the  lung  may  become  as  small 
as  a  man's  fist.  But  in  pleurisy  there  are  no  signs  of 
cavities  as  in  fibroid  phthisis,  and  in  the  former  there 
are  diminution  or  absence  of  the  respiratory  murmur 
and  fremitus,  the  very  opposite  being  the  case  in  con- 
solidation of  lung  unless  there  be  obstruction  due  to 
bronchial  stricture  and  the  like.  The  heart  is  not  so 
much  displaced  in  j)leurisy,  and  in  the  latter  disease  tlie 
patient  is  also  usually  in  better  general  condition  and 
with  less  cough  and  expectoration. 

In  cancer  of  the  lung,  in  addition  to  the  cancerous 
cachexia,  dullness  over  the  affected  i)art  may  extend 
across  the  median  line,  with  inward  pressure  signs  on 
the  trachea  and  oesophagus  due  to  cancerous  enlarge- 
ment of  mediastinal  lymphatic  glands.  The  percus- 
sion dullness  from  solidified  lung-tissue,  on  the  con- 
trary, never  extends  across  the  median  line.  The  sputa 
in  the  two  diseases  would  also  differ. 

Compression  atelectasis  from  pleuritic  effusion,  aneu- 
rismal  or  other  tumors,  deformities,  and  the  like  (p.  60), 
may  be  readily  differentiated  by  careful  examination 
and  ascertaining  the  cause  of  the  atelectasis. 

During  the  recent  Berlin  Medical  Congress,  Profes- 
sor Ewald,  of  Berlin,  expressed  the  opinion  that  chronic 
pneumonia  is  phthisis,  the  reason  why  it  is  chronic 
being  due  to  the  presence  of  the  tubercle  bacillus.  Ac- 
cording to  Williams,  tlie  tubercle  bacillus  is  nearly 
always  found  even  in  the  so-called  potter's  and  knife- 
grinder's  lung  and  similar  diseases. 


CHAPTER  IV. 

Diseases  in  which  the  breath  and  voice  sounds  are  interrupted  in 
their  transmission  to  the  chest  walls,  with  consequent  diminu- 
tion, or  absence,  of  vocal  fremitus,  respiratory  murmur,  and 
pectorophony. — Diseases  of  the  pleurse. — Thickened  pleurae. — 
Fluid  or  air,  or  both,  in  the  pleural  cavities. 

PLEURISY. 

Pleurisy,  or  pleuritis,  is  inflammation  of  one  or  both 
plenrse.  These,  consisting  of  two  layers,  \dsceral  and 
costal,  form  a  closed  sac  on  each  side.  These  sacs  do 
not  communicate,  but  approach  each  other  closely  be- 
hind the  median  line  of  the  sternum,  from  a  point  cor- 
resiDonding  with  the  upper  borders  of  the  second  costal 
cartilages,  to  the  upjier  borders  of  the  fourth,  where 
they  diverge.  The  left  pleura  turns  obliquely  do^\^l- 
ward  and  outward,  but  within  the  left  nii^ple  to  the 
fifth  cartilage,  leaving  a  jDortion  of  the  heart  uncovered 
— the  superficial  area  of  cardiac  dullness;  thence  in- 
ward to  the  upper  border  of  the  sixth,  where  it  turns 
outward  again  to  the  lower  border  of  the  sixth  costal 
cartilage  on  the  left  mamillary  line ;  thence  to  the  lower 
border  of  the  eighth,  on  the  left  axillary  line;  the 
ninth  ril:*  on  the  scapular  line  (or  line  let  fall  perpen- 
dicularly from  the  inferior  angle  of  the  scapula),  and 
the  tenth  rib  on  the  vertebral  line  (close  to  the  spinal 
column). 

The  right  pleura  continues  down  behind  the  median 
line  of  the  sternum  to  the  upper  border  of  the  sixth 


I'SQ  PHYSICAL    DIAGNOSIS. 

costal  cartilage  where  it  turns  off  nearly  at  right  angles 
along  the  npper  border  of  the  liver.     On  the  right  axil 
lary  line  the  right  pleura  reaches  down  to  the  upper 
border  of  the  eighth  rib,  on  the  scapular  line  the  ninth 
rib,  and  on  the  Aertebral  line  the  tenth  rib. 

The  following  is  a  summary  of  the  lower  limits  of 
the  pleurse: 

Left  Pleura. — On  sternal  line,  upper  border  of  fourth 
costal  cartilage.  On  mamillary  line,  low^er  border  of 
sixth.  On  axillary  line,  lower  border  of  eighth  rib.  On 
scapular  line,  ninth  rib.     On  vertebral  line,  tenth  rib. 

Rigid  Pleura. — On  sternal  line,  upper  border  of 
sixth  costal  cartilage.  On  mamillary  line,  the  same. 
On  axillary  line,  upper  border  of  eighth  rib.  On  scapu- 
lar line,  the  ninth  rib.     On  vertebral  line,  tenth  rib. 

These  limits  vary  somewhat  with  deep  inspiration, 
also  in  emphysema,  effusion  of  fluids  into  the  pleural 
sacs,  pneumothorax,  and  the  like. 

The  chief  function  of  the  pleurae  is  to  furnish  a 
small  amount  of  lubricating  material  within  the  sacs, 
so  that  the  layers  can  easily,  and  witliout  noise,  glide 
on  each  other,  and  thus  facilitate  respiratory  move- 
ments. In  this  respect  they  resemble  the  synovial 
membrane  of  a  large  joint.  And  as  anchylosis  affects  a 
joint,  so  are  pleuritic  adhesions  injurious  in  proportion 
as  they  are  extensive,  and  restrict  the  movements  of 
respiration. 

Pleurisy  may  be  divided  into  two  classes:  (1)  dry 
pleurisy,  and  (2)  pleurisy  with  effusion.  Of  each  of 
these  classes  there  are  three  varieties,  (1)  acute,  (2)  sub- 
acute, and  (3)  chronic. 

Dry  pleurisy.^  circumscribed  pleurisy,  pleurisy  with 


PLEURISY.  137 

scant  fibrinous  exudation,  or  pleurisy  without  effu- 
sion, is  a  very  common  affection  and  often  escapes 
notice.  It  is  usually  this  class  of  pleurisy  that  is  found 
in  connection  with  pulmonary  consumption,  where  the 
inflammation  crops  out  here  and  there  in  spots  on  the 
perijjhery  of  the  lung.  Or  it  may  be  secondary  to  ex- 
tension of  inflammation  from  cancer  or  other  neoplas- 
tic growths.  It  may  be  caused  by  fracture  of  a  rib  or 
other  surgical  injury,  or  it  may  be  due  to  exposure 
to  a  draught  of  cold,  and,  flnally,  it  may  come  on  with- 
out any  known  cause.  In  idiopathic  dry  pleurisy  the 
physical  signs  are  few.  Usually  there  is  jerking  respi- 
ration or  a  catch  in  the  breath,  as  it  is  called,  owing  to 
the  sharp  pain  in  the  side.  This  pain  is  usually  near 
one  nipple  or  the  other.  On  palpation  the  fremitus  is 
unchanged,  owing  to  the  small  extent  of  the  affection, 
and  the  slight  ]3athological  change  x)roduced.  This  con- 
sists in  a  small  spot  of  thickening  or  roughening  of  the 
pleura.  Sometimes  if  there  be  scant  fibrous  exudation, 
a  point  of  adhesion  may  result.  The  pulse  is  not  ac- 
celerated and  there  is  no  fever.  The  percussion  res- 
onance is  normal.  On  auscultation  a  slight  pleuritic 
friction  or  crex)itation  may  be  heard,  especially  on  in- 
spiration. In  a  few  days,  however,  this  may  have  dis- 
appeared. When  no  adventitious  sound  is  present  it 
might  be  a  question  as  to  whether  the  affection  was  dry 
pleurisy,  pleurodynia  or  intercostal  neuralgia.  But  dry 
pleurisy  invariably  has  only  one  point  of  pain,  Avhicli 
the  patient  can  locate  with  the  point  of  the  finger.  In 
intercostal  neuralgia  there  are  usually  three  points  of 
tenderness ;  near  the  spinal  column,  at  the  anterior  ex- 
tremity of  the  nerve,  and  about  its  middle.     Besides 


138  PHYSICAL    DIAGNOSIS. 

this  tlie  patient  will  probably  give  the  history  of  previ- 
ous attacks  of  neuralgia  in  other  localities  as  well  as 
intercostal.  In  ^pleurodynia,  or  myalgia,  there  is  ex- 
treme tenderness  in  the  muscles  of  the  side.  The  pa- 
tient shrinks  from  touch,  and  there  is  pain  on  motion. 
Lumbago,  or  other  muscular  rheumatism,  is  often  as- 
sociated. 

Pleurisy  toith  effusion  is  inflammation  of  the 
pleura,  attended  vdXh  sero-fibrinous  effusion  into  the 
sac  as  the  result  of  interstitial  exudation.  It  may  be 
primary  or  secondary,  and  either  of  these  may  be  acute, 
subacute  or  chronic.  The  latter  disease  is  sometimes 
described  as  empyema  (pyothorax),  but  this  wuU  be  de- 
scribed separately,  and  by  chronic  j)leurisy  with  effu- 
sion will  be  meant  old  cases  of  pleurisy  with  sero-fibri- 
nous, or  serous,  effusion. 

Acute  pleurisy  with  effusion,  lasts  about  two  weeks, 
usually,  and,  like  acute  lobar  pneumonia,  has  three 
stages.  Undoubtedly,  in  many  cases,  the  exciting 
cause  is  exposure  to  cold  and  wet,  wdien  it  is  said  to  be 
primary,  although  some  predisposing  cause,  notably 
lowered  vitality,  must  also  exist.  According  to  Lan- 
douz3%  of  Paris,  many  of  these  cases  of  pleurisy  d  fri- 
gore,  so-called,  are  merely  symptomatic  of  latent  tuber- 
culosis and  are  not  piimary.  This  is  probably  true 
for  Paris,  but  not  all  climates,  as  I  have  learned  from 
personal  experience,  as  well  as  by  inquiry  at  the 
Bromj)ton  Hospital  in  London,  and  other  hosiDitals. 

Acute  pleurisy  with  effusion  may  occur  secondarily 
in  the  course  of  articular  rheumatism,  Bright's  disease 
of  tlie  kidneys,  scarlet  fever,  measles  and  pysemic  con- 
ditions. 


PLEURISY.  139 

The  first  stage  of  acute  pleurisy  with  effusion  is 
the  dry  stage  of  congestion,  and  lasts  from  a  few  hours 
to  twenty-four  hours,  or,  in  some  cases,  even  longer. 

The  second  stage,  that  of  effusion,  lasts  about  five 
days  on  the  average.  The  amount  of  liquid  effused  is 
not  usually  so  great  as  in  the  subacute  or  chronic  form, 
and  is  more  fibrinous. 

The  third  stage,  that  of  absorption,  usually  begins  by 
the  eighth  day,  and  in  about  two  weeks,  in  an  ordinary 
case,  recovery  may  be  said  to  be  complete.  Tlie  phys- 
ical signs  differ  according  to  the  stage  of  the  disease. 

First  Stage. — The  physical  signs  are  similar  to  those 
of  dry  pleurisy  already  described,  only  more  severe,  as 
the  disease  under  consideration  is  more  extensive. 

Inspection.— ThQ  patient  lies  on  the  affected  side, 
since  by  this  means  the  respiratory  movements  of  that 
side  would  be  restricted,  while  those  of  the  unaffected 
side  would  be  free.  But  with  all  precautions  the  resi^i- 
rations  will  be  jerking,  due  to  pain  in  the  side.  The 
respiratory  movements  are  restricted  on  the  affected 
side,  somewhat  exaggerated  on  the  opposite  side. 

Palpation. — The  vocal  fremitus  will  be  unchanged 
or  very  slightly  diminished,  ovdng  to  the  slight  thick- 
ening of  the  pleura  from  congestion.  But  in  persons 
with  thin  chest  walls  a  friction  fremitus  over  the  dis- 
eased pleura  may  sometimes  be  felt. 

Percussion  would  yield  normal  resonance  or  slight 
dullness  if  the  i^leura  be  slightly  thickened  by  the  con- 
gestion. 

Auscultation. — The  respiratory  murmur  would  be 
disturbed  in  its  rhythm  by  the  jerking  due  to  pain,  but 
its  quality  would  be  normal ;  so  would  the  i3ectoroph- 


140  PHYSICAL    DIAGNOSIS. 

ony  (vocal  resonance),  but  both  wonld  be  somewhat 
diminished  in  intensity,  due  to  slight  thickening  of  the 
pleura  from  congestion. 

A  pleuritic-  friction  sound  is  usually  heard  on  inspi- 
ration, expiration,  or  both.  Honore,  of  Paris,  in  1819, 
was  the  first  to  call  attention  to  this  adventitious  sound 
and  to  point  out  its  true  pathological  significance. 

All  intra-pleural  adventitious  sounds  are  heard  usu- 
ally more  distinctly  on  inspiration  than  on  expiration, 
since  the  two  layers  of  pleurae  are  brought  closer  and 
more  forcibly  together  in  the  former  act  than  in  the 
latter.  Those  due  to  rubbing  together  of  opposing 
roughened  surfaces,  and  stretching  of  adhesions,  are 
often  heard  only  on  inspiration,  while  intra-pleural 
rales,  due  to  viscid  exudative  material,  or  perverted 
secretion,  are  often  heard  both  on  insi^iration  and  ex- 
piration, and  simulate  verj^  closely  bronchial  and  other 
moist  rales.  Pleuritic  friction  may  sound  like  the 
creaking  or  rubbing  together  of  leather,  or  treading  in 
deep,  crusty,  snow.  Or  it  may  be  merely  grazing  or 
crepitating.  Distinct  pleuritic  friction  sounds  are  not 
infrequently  interrupted,  that  is  to  say,  there  may  be 
two  or  three  consecutive  friction  sounds  during  in- 
spiration, expiration,  or  both.  If  the  chest  walls  are 
thin  and  the  friction  well  marked,  a  localized  friction 
fremitus  may  be  felt  on  palx)ation  as  already  stated. 

Second  Stage. — After  effusion  has  taken  place,  we 
obtain  the  physical  signs  to  be  described  in  connection 
with  chronic  (subacute)  pleurisy,  with  effusion  (p.  142). 
They  are  chiefly  those  of  interrupted  transmission  of 
sound,  due  to  the  presence  of  fluid  in  the  pleural  cavity 
acting  as  a  partition  or  diaphragm,  as  well  as  flatness 


PLEURISY.  141 

or  marked  dullness  on  percussion  over  the  site  of  the 
effusion. 

Third  Stage. — After  absorption  has  sufficiently  pro- 
gressed, the  friction  sound,  which  had  disai^peared 
during  effusion,  reappears— ;/r?*c^/6>  redux.  This  also 
finally  disappears  in  favorable  cases,  as  the  conditions 
producing  it  clear  up,  and  the  physical  signs  again  be- 
come those  of  health. 

An  all-important  question  arises  in  connection  with 
this  disease.  When  must  the  chest  be  tapped?  If  life 
be  threatened,  owing  to  great  effusion,  tap  at  once.  Do 
not  draw  off  all  the  fluid,  however,  but  only  enough  to 
allow  the  patient  to  breathe  easily.  But  unless  symp- 
toms of  suffocation  are  urgent,  and  they  very  rarely 
are,  do  not  draw  any  of  the  fluid  off  before  the  end  of 
the  third  week.  Why?  Because  if  the  fluid  be  dra^\^l 
off  too  early,  and  before  active  inflammation  has  sub- 
sided, adhesion  of  the  two  layers  of  the  pleura  will  re- 
sult, which  would  be  one  of  the  most  unfortunate  termi- 
nations that  the  disease  could  possibly  have.  The  fluid 
in  the  sac  keejDS  the  two  layers  apart.  To  draw  it  off 
too  early  would  not  only  thwart  nature,  but  would  be 
malpractice.  According  to  Potain,  of  Paris,  and  others, 
only  in  rare  and  urgent  cases  should  any  fluid  be  with- 
drawn before  the  twenty-flrst  day  of  the  disease,  and 
even  then,  only  a  part  of  it. 

Subacute  pleurisy  with  effusion  usually  results  from 
a  badly  managed  case  of  the  acute  variety,  or  in  cases 
where  the  iDatient  is  in  bad  condition  when  attacked, 
or  iDerhaps  is  tuberculous. 

Chronic  pluerisy  \n.i\\  gi^eat  effusion  is  described 
by  many  authors  as  subacute.     It  rarely  follows  the 


142  PHYSICAL   DIAGNOSIS. 

acute  form,  but  is  usually  chronic  from  tlie  first,  and 
is  not  infrequently  of  tuberculous  origin.  The  patient 
may  not  complain  of  pain  in  the  side  at  all.  Usually 
there  is  a  hacking  reflex  cough,  without  much  ex- 
pectoration. The  appetite  is  poor  and  emaciation 
follows,  attended  sometimes  by  hectic  fever.  The  pa- 
tient applies  to  a  physician,  who,  being  satisfied  to  ex- 
amine the  apices  of  the  lungs  only,  finds  signs  of  con- 
solidation from  compression  at  one  apex,  and  hastily 
makes  a  diagnosis  of  phthisis  simply.  Had  he  taken 
the  trouble  to  examine  the  patient  carefully  down  to 
the  waist,  he  would  have  found  pleuritic  effusion  with 
the  following  physical  signs: 

Inspection. — Usually  there  are  bulging  of  the  inter- 
costal spaces  over  the  seat  of  effusion,  which  is  always 
at  the  lower  part  of  the  thorax,  displacement  of  the 
apex  of  the  heart  laterally,  in  a  direction  opposite  to 
the  seat  of  pressure  from  the  effusion,  and  diminution 
of  respiratory  movements  on  the  affected  side  in  pro- 
portion to  the  amount  of  effusion,  with  exaggerated 
respiratory  movements  on  the  unaffected  side.  Col- 
lapse not  infrequently  follows  removal  and  absorption 
of  the  fluid  and  the  other  side  now  appears  abnormally 
large,  partly  from  comparison  with  the  collapsed  side, 
but  partly  also  because  the  lung  has  become  actually 
larger  in  volume  from  vicarious  emphysema. 

Where  the  case  is  not  of  long  standing,  however,  and  the  pa- 
tient has  chest  walls  covered  with  fat  and  luuscle,  the  bulging 
f)ver  the  alTected  part  may  not  be  observable.  Such  a  case  ap- 
plied to  me  in  May,  1885.  He  was  a  fire-stoker,  aged  thirty-two. 
The  chest  was  perfect  in  outline.  Upon  my  advice  he  applied  to 
the  late  Prof.  E.  D.  Hudson,  whom  I  then  assisted  at  the  New 
York  Polyclinic.    Aspiration  proved  that  the  right  pleural  cavity 


PLEURISY.  143 

contained  an  abundance  of  sero-fibrinous  fluid.  In  this  case  the 
effusion  was  due  to  tuberculosis,  as  post-mortem  examination 
proved,  nearly  two  years  afterAvard. 

Palpation. — Tlie  vocal  fremitus  is  diminished  or  ab- 
sent over  the  effusion,  according  to  its  amount.  Above 
the  level  of  the  effusion,  where  the  lung  is  in  a  condi- 
tion of  compressed  atelectasis,  the  fremitus  is  increased. 
These  signs  may  evidently  change  with  position  of  the 
patient,  unless  the  lung  is  tixed  in  its  iDosition  by  ad- 
hesions. The  apex-beat  of  the  heart  may  be  felt  out  of 
its  normal  position.  It  sometimes  happens  that  a  spot 
of  fremitus  is  felt  somewhere  over  the  seat  of  effusion. 
This  is  due  to  the  telephoning  of  the  voice  to  the  spot 
along  a  string  of  adhesion,  or  else  it  may  be  extended 
by  a  rib,  as  in  case  of  a  heart  murmur.  Intercostal 
fluctuation  may  sometimes  be  felt. 

Percussion. — Over  the  fluid  there  is  flatness  on  per- 
cussion, unless  the  chest  walls  are  thick,  in  which  case 
marked  dullness  will  be  elicited,  as  the  walls  themselves 
will  give  out  some  resonance,  like  the  thigh,  or  the  del- 
toid muscle.  But  where  the  chest  walls  are  thin  and  the 
fluid  abundant,  flatness,  or  absence  of  resonance,  except 
what  is  obtained  out  of  the  finger  as  a  pleximeter  and 
the  chest  walls,  is  the  rule.  Besides,  there  is  also  a 
feeling  of  resistance  to  the  finger  on  palpatory  percus- 
sion in  these  cases.  Tlie  upper  line  of  the  fluid,  instead 
of  being  j)erfectly  level,  is,  according  to  some,  curved 
somewhat  like  the  letter  S,  forming  what  is  termed  the 
curved  line  of  Ellis.  It  is  lowest  in  front,  highest  at 
the  side,  and  averaged  between  the  two  i)osteriorly. 
This  line  changes  with  i^osition  of  the  patient  unless 
prevented  by  adhesions.     Over  the  compressed  lung 


144  PHYSICAL    DIAGNOSIS. 

there  is  dullness  on  percussion,  but  not  infrequently 
under  the  clavicle  on  the  side  of  effusion  we  obtain  tym- 
panicity  (Skodaic  resonance).  This  occurs  more  fre- 
quently in  front  than  behind.  The  true  cause  of  this 
tympanicity  was  lirst  exx)lained  by  Skoda.  The  pul- 
monary vesicles  being  obliterated  by  compression,  as 
well  as  the  ultimate  bronchial  tubes,  the  compressed 
pulmonary  perii)hery  is  gathered  around  a  bundle  of 
dilated  bronchial  tubes  that  form  an  irregular  cavity, 
which  yields  tympanicity  on  percussion.  There  is  ex- 
aggerated percussion  resonance  over  the  other  lung,  ow- 
ing to  its  being  in  a  state  of  vicarious  emphysema.  It 
sometimes  happens  that  tympanicity,  or  even  cracked- 
pot  resonance,  may  be  obtained  over  the  seat  of  effusion. 
This  is  especially  true  in  case  of  children.  This  is  ow- 
ing to  the  fact  that  the  force  of  the  percussion  blow  ex- 
tends to  the  stomach,  transverse  colon  or  some  neigh- 
boring viscus  distended  by  air.  Very  gentle  percus- 
sion, therefore,  in  children,  is  necessary  to  avoid  tym- 
panicity. The  cracked-pot  sound,  if  obtained,  would 
be  due  to  concussion  of  air  in  some  hollow  viscus, 
and  not  to  its  forcible  escape. 

Auscultation. — In  listening  over  the  seat  of  the  effu- 
sion the  respiratory  murmur  is  diminished  or,  generally, 
absent.  This  is  due  to  the  fact  that  the  lung  is  pressed 
away  from  the  site  of  effusion,  which  not  only  does  not 
conduct  the  breath  and  voice  sounds  but  interrupts 
them.  The  pleural  cavity,  containing  fluid,  acts  like  a 
partition.  The  thicker  the  partition  the  less  distinctly 
does  sound  pass  through  it.  Sometimes,  however,  owing 
to  a  string  of  adhesion,  bronchial  breathing  may  be 
telephoned  to  a  spot  somewhere  over  the  site  of  effusion, 


PLEURISY. 


14^ 


or  else  it  may  be  transmitted  there  along  a  rib.  Above 
the  seat  of  effusion  and  over  the  comi3ressed  lung  we 
hear  bronchial  breathing.  But  occasionally  cavernous 
breathing  is  heard  over  the  seat  of  percussion  tym- 
23anicity.  Over  the  other  lung  the  breathing  becomes  ex- 
aggerated, owing  to  the  extra  work  that  lung  has  to  do. 


Fig.  15.— Diagram  showing  Pleurisy  with  Effusion,  Compressed  Lung,  a  String 
of  Adhesion  from  the  Compressed  Limg  to  Thoracic  Wall,  Dilated  Bronchi  and  Dis- 
placement of  Organs  to  the  opposite  side. 

Pectorophony  (vocal  resonance  )  is  very  much  dimin- 
ished over  the  effusion,  but  is  not  entirely  absent  if  the 
voice  of  the  patient  is  loud  enough.  The  whispered 
voice,  like  the  respiratory  murmur,  is  usually  absent. 
But  in  speaking  out  loud,  distant  or  weak  broncho- 
phony is  heard.  If  this  distant  bronchophony  is  trem- 
ulous, due  to  vibrating  fluid,  it  is  called  jegophony 

(goat's  voice),     ^gophony  is  usually  obtained  where 
10 


146  PHYSICAL    DIAGI^OSIS. 

the  effusion  is  not  great,  otherwise  the  bulk  of  fluid 
cannot  be  thrown  into  vibration.  It  is  heard  most  com- 
monly about  the  lower  angle  of  the  scapula,  along  the 
npper  border  of  the  fluid,  when  it  is  at  that  point.  A 
thin  stratum  of  encapsulated  fluid  may  also  be  thro^^Ti 
into  tremulous  \dbrations  by  the  voice,  thus  causing 
segophony. 

Thickened  Pleura. — It  not  infrequently  happens  that 
after  effusion  has  disappeared  the  pleura  remains 
thickened.  Indeed  it  is  of  common  occurrence  to  ex- 
amine patients  with  only  thickened  jDleura  without 
effusion.  In  these  cases  the  thickened  pleura  also  acts 
as  an  interrupter  to  the  transmission  of  sound.  The 
respiratory  murmur,  i^ectorophony  (vocal  resonance), 
and  fremitus  are  also  diminished,  and  percussion  dull- 
ness is  noticeable,  in  proportion  to  the  thickening.  A 
string  of  pleuritic  adhesion,  however,  may  transmit 
sound  on  the  principle  of  a  telephone.  But  extensive 
13leuritic  thickening  is  a  different  condition,  which  acts 
rather  as  a  diaphragm,  or  partition,  than  a  telephone. 

Differential  Diagnosis. — The  diagnosis  of  idiopathic 
dry  pleurisy,  from  pleurodynia  and  intercostal  neu- 
ralgia, has  already  been  considered.  The  diagnosis  be- 
tween acute  pleurisy  with  effusion  and  acute  lobar 
pneumonia  is  readily  made,  generally.  In  pleurisy 
with  effusion  there  is  interruption  to  the  transmission 
of  sound  and  the  respiratory  murmur,  and  the  vocal 
resonance  and  fremitus  over  the  affected  part  are  di- 
minished or  absent,  but  markedly  increased  in  pneu- 
monia. The  line  of  flatness  or  dullness  in  pleurisy  often 
changes  with  position  of  tlie  patient,  but  never  in  pneu- 
monia.  In  cancer  of  the  lung  there  are  signs  of  consoli- 


PLEURISY.  147 

dation,  usually  at  the  upper  and  front  part  of  the  lung 
with  increased  conducting  power,  the  dullness  often 
extending  across  the  median  line,  o^\dng  to  cancerous 
enlargement  of  mediastinal  glands.  In  pleurisy  with 
effusion,  the  affection  is  at  the  lower  part  of  the  thorax 
posteriorly,  with  interruption  to  transmission  of  sound 
and  consequent  diminution  or  absence  of  resjjiratory 
murmur  and  fremitus.  The  line  of  dullness  in  cancer 
does  not  change  with  position  of  the  patient.  In  phthi- 
sis we  also  have  signs  of  consolidation  and  increased  con- 
duction power  of  lung  tissue,  instead  of  the  interrup- 
tion of  transmission  of  sound,  as  in  pleurisy.  In  old 
cases  of  pleuritic  effusion  and  compressed  lung  it  is 
only  carelessness  should  the  physician  confine  his  ex- 
amination to  the  top  of  the  lung  and  omit  the  lower 
part  of  the  thorax.  Thoracic  aneurism  has  been  mis- 
taken for  pleurisy  with  effusion,  but  such  cases  are  very 
rare  (see  Aneurism). 

Hydatid  disease  of  the  lungs  may  be  mistaken  for 
pleurisy  with  effusion.  Such  a  case  has  aready  been 
alluded  to  (see  Hydatid  Disease  of  the  Lungs,  p.  109). 
There  were  signs  of  effusion  in  the  upper  part  of  the 
right  pleural  cavity.  The  location  excited  suspicion, 
as  pleurisy  usually  affects  the  lower  part  of  the  thorax. 
Under  the  microscope  some  of  the  aspirated  fluid  showed 
the  presence  of  hooklets  and  scolices.  In  any  case  of 
doubt  the  hypodermic  syringe  may  be  used  to  test  the 
presence  or  absence  of  fluid. 

The  differentiation  of  pleurisy  with  effusion  from 
enlargement  of  the  liver  and  spleen  is  sometimes 
difficult. 

The  upper  limits  of  the  liver  have  been  already  given. 


148  PHYSICAL    DIAGjS^OSIS. 

being  the  same  as  the  lower  limits  of  the  right  lung 
and  pleura.  The  lower  limits  of  the  liver  correspond 
to  the  free  margin  of  the  ribs  in  the  right  hypochon- 
driac region,  the  tenth  interspace  on  the  right  axil- 
lary line,  and  the  eleventh  rib  on  the  scapular  line,  be- 
low which  it  is  lost  in  the  dorsal  muscles. 

The  liver  usually  enlarges  dowTiward,  but  sometimes 
iipward,  especially,  according  to  Niemeyer,  in  case  of 
abscess  or  hydatid  disease.  If  the  case  be  one  of  simple 
enlargement  of  the  liver  ui:)ward,  the  line  of  percussion 
dullness  will  extend  up  higher  in  front  than  behind, 
the  organ  ascends  and  descends  during  respiration,  the 
respiratory  sounds  posteriorly  though  feeble,  are  not, 
according  to  Da  Costa,  entirely  absent,  and  the  heart, 
if  displaced  at  all,  is  pushed  upward.  The  signs  do 
not  change  with  position  of  the  patient,  as  they  often 
(not  always)  do  in  pleurisy  with  effusion.  In  the  latter 
disease,  occurring  on  the  right  side,  the  liver  may  be 
pushed  down,  giving  dullness  on  loercussion  below  the 
ribs.  But,  with  the  patient  in  the  sitting  or  standing 
position,  the  line  of  dullness  will  extend  up  as  high 
jjosteriorly  as  in  front,  and  the  liver  does  not  move 
up  and  down  during  respiration,  but  it  is  permanently 
depressed.  Moreover,  a  small  yielding  interval  may 
be  usually  felt  between  the  lower  border  of  the  ribs  and 
a  normal  liver  that  has  been  pushed  down  by  fluid, 
whereas  no  such  sj^ace  exists  in  case  of  enlargement  of 
the  liver  downward. 

According  to  Niemeyer,  the  normal  dullness  of  the 
spleen  is  from  the  upper  margin  of  the  eleventh  rib, 
along  the  axillary  line,  to  the  ninth  rib ;  anteriorly  to 
a  line  drawn  from  the  anterior  end  of  the  eleventh  rib 


PLEURISY.  149 

to  tlie  nipple ;  but  x^osteriorly  it  cannot  be  defined  from 
the  dullness  of  the  left  kidney,  but  its  greatest  thick- 
ness from  before  back,  is  about  two  inches.  The  spleen 
usually  enlai'ges  downward  and  forward,  and  then 
may  be  felt  below  the  ribs  in  the  abdominal  cavity. 
But  according  to  Memeyer  and  others  it  may  extend 
upward,  rarely  higher  than  the  fifth  rib,  without  going 
below  the  margin  of  the  ribs  at  all,  even  in  cases  of  de- 
cided enlargement.  Intestines  distended  with  gas,  and 
the  like,  push  it  upward  and  backward  as  in  typhus, 
but  if  it  enlarges  upward,  as  in  intermittent  fever,  it 
extends  toward  the  axilla.  The  heart  is  pushed  up- 
ward, and  not  sidew^ays,  the  latter  usually  being  the 
case  in  large  pleuritic  effusion.  The  enlarged  spleen 
moves  up  and  down  perceptibly  during  respiratioii, 
the  level  of  dullness  changing  an  inch  sometimes 
on  respiratory  percussion,  accordingly  as  percussion 
occurs  at  the  end  of  a  full  inspiration  or  expira- 
tion. The  area  of  dullness  is  less  when  the  patient 
lies  on  the  right  side  in  enlarged  sjDleen,  but  it  does 
not  otherwise  change  with  i^osition  of  the  i^atient 
as  is  often  (not  always)  the  case  in  pleuritic  effu- 
sion. In  enlarged  spleen,  the  resj)iratory  sounds  are 
feeble  over  the  part,  but,  according  to  Da  Costa,  the 
vocal  vibrations  are  mostly  unimi)aired,  whereas  they 
are  usually  absent  in  effusion.  The  rational  signs  of 
the  case  and  i^revious  history,  with  reference  to  pleu- 
risy, intermittent  fever,  and  the  like,  will  aid  in  arriving 
at  a  correct  diagnosis.  Lastly  the  hypodermic  syringe 
may  be  used  to  test  the  presence  or  absence  of  fluid  in 
the  pleural  ca\dty.  Extensive  plastic  (adhesive)  pleurisy 
without  effusion  would,  among  other  points  of  differ- 


150 


PHYSICAL    DIAGISTOSIS. 


ence,  cause  no  fullness  of  the  chest- walls,  like  enlarged 
liver  or  spleen,  and  might  even  produce  contraction. 

In  case  of  effusion  into  the  pleural  cavity  it  may  be- 
come necessary  to  perform  the  operation  of  paracen- 
tesis thoracis  (thoracentesis,  tapping,  or  aspirating  the 
chest).  This  may  be  done  by  means  of  Potain's  as- 
pirator, or  better  still,  i^erhaps,  by  Dieulafoy's  instru- 
ment.    I  have  had  a  guard,  regulated  by  a  screw,  fitted 


Fig.  16.—  Potain's   Aspirator,  and  Needle  with  Movable  Guard  O. 

to  the  needles  used  by  myself.  By  this  means  the 
needle  cannot  accidentally  penetrate  any  deeper  than 
is  necessary  to  draw  off  the  fluid. 

"Where  shall  we  puncture  ?  According  to  Bow- 
ditch,  find  the  inferior  limit  of  the  sound  lung  be- 
hind and  tap  two  inches  higher  than  this  on  the 
pleuritic  side,  at  a  point  in  a  line  let  fall  peri:)en- 
dicularly  from  the  (inferior)  angle  of  the  scapula. 
Push  in  the  intercostal  space  here  with  the  point  of 
the  finger,  and  plunge  in  the  needle  quickly  and  firmly 


PLEURISY.  151 

at  the  depressed  part,  in  order  to  get  through,  false 
membranes.  If  no  fluid  be  obtained  here,  puncture  a 
little  higher  up  and  further  toward  the  axillary  line. 
Bowditch's  point  of  puncture  has  the  advantage  over  all 
others  of  allowing  the  pleural  sac  to  be  entered  at  the 
most  dependent  point,  with  less  risk  of  perforating  the 
diaphragm  and  causing  peritonitis,  though  it  possesses 
the  disadvantage  of  obliging  the  patient  to  be  in  a  sit- 
ting posture,  if  that  be  any,  instead  of  the  recumbent, 
during  the  operation. 

Fraentzel,  of  Berlin,  prefers  a  point  haK  way  between 
the  mammillary  and  axillary  lines  in  the  fifth  interspace 
on  the  left  side,  and  in  the  fourth  on  the  right,  the  pa- 
tient being  in  the  recumbent  position.  Aufrecht,  of  Mag- 
deburg, prefers  a  point  on  the  axillary  line  in  the  fourth 
interspace  on  both  sides,  the  patient  being  recumbent. 
Puncturing  the  diaphragm  with  resulting  fatal  peri- 
tonitis has  occurred  in  this  operation  by  penetrating 
the  chest-walls  too  low  down.  In  general,  the  puncture 
should  be  made  on  the  axillary  line,  between  the  fifth 
and  sixth  ribs  on  the  left  side,  and  between  the  fourth 
and  fifth  ribs  on  the  right  side  to  avoid  the  liver. 

In  what  cases,  speaking  of  adults,  shall  the  operation 
be  performed,  and  how  much  fluid  be  withdrawn?  Ac- 
cording to  Anstie  (Reynold's  System  of  Medicine)  it 
should  be  done  (1)  in  all  cases  where  the  fluid  fills  one 
pleura  and  begins  to  compress  the  other  lung;  (2)  in 
all  double  pleurisies  where  the  total  fluid  would  about 
fill  one  pleural  cavity ;  (3)  in  all  cases  of  large  amount 
of  effusion  where  there  have  been  one  or  more  fits  of 
orthopnoea ;  (4)  in  all  cases  where  the  fluid  is  purulent, 
and  (5)  in  all  cases  where  fluid,  occupying  at  least  half 


152  PHYSICAL    DIAGNOSIS. 

of  a  pleural  canity,  lias  existed  for  a  month  and  shows 
no  signs  of  being  absorbed. 

Neither  Bowditch,  Murchison,  nor  Anstie  recommend 
to  withdraw  all  the  fluid,  but  only  so  much  as  will 
substantially  relieve  the  mechanical  distress  caused  by 
pressure.  In  most  cases  that  is  all  that  is  necessary  to 
excite  the  natural  process  of  absorption.  They  all  stop 
the  withdrawal  of  fluid  the  moment  the  patient  begins 
to  complain  of  constricting  pain  in  the  chest  or  epigas- 
trium. 

Fraentzel,  of  Berlin,  operates  usually  when  the  fluid 
reaches  uj)  to  the  third  rib,  and  oedema  of  the  other  lung 
is  threatened.  He  takes  out  about  flf  ty  ounces  of  fluid 
and  repeats  the  oj)eration  in  three  to  five  days  when 
necessary. 

Aufrecht  recommends  (1)  that  a  trial  puncture  by 
Pravaz's  syringe  be  made  before  operating.  The  ordi- 
nary hypodermic  syringe  with  a  perfectly  fitting  piston 
and  carefully  adjusted  long  needle  (disinfected)  is 
sufiicient.  (2)  If  there  is  reason  to  believe  that  less  than 
forty -five  ounces  of  fluid  will  be  discharged,  the  opera- 
tion had  better  be  usually  left  undone.  (3)  'Not  more 
than  eighty  ounces  of  fluid  should  be  evacuated.  (4) 
The  thoracentesis  should  not  be  repeated  unless  a  vital 
indication  demand  it.  (5)  The  operation  of  drawing 
off  part  of  the  fluid  should  be  performed  in  all  cases 
of  large  effusions  as  soon  as  the  patient  is  seen,  irre- 
spective of  the  degree  of  temperature.  Other  authors 
draw  off  the  fluid  at  an  earlier  date  than  any  of  those 
mentioned,  and  do  not  hesitate  to  withdraw  it  all. 

In  case  of  empyema  (pyothorax)  a  pennanent  drain- 
age tube,  securely  fastened  to  prevent  its  droj)i3ing  into 


HYDROTHORAX — EMI»  V  KM  A.  153 

che  pleural  cavity,  promises  better  results  than  repeated 
aspiration.  The  tube  may  be  introduced  through  a 
free  opening  as  low  down  as  the  seventh  intercostal 
sj)ace  on  the  axillary  line,  whereas  the  trocar  (needle) 
should  not  be  pushed  into  the  i)leural  cavity  lower  down 
than  already  mentioned. 

HYDROTHORAX. 

Hydrotliorax  is  a  dropsical  and  non-inflammatory 
affection,  in  which  there  is  fluid  in  both  jjleural  cavities. 
It  is  the  result  of  a  serous  transudation  and  not  of  an 
inflammatory  exudation,  and  is  usually  associated  with 
general  dropsy  from  some  cause.  Hydroperitoneum 
and  hydro-pericardium  may  exist  at  the  same  time.  Tlie 
physical  signs  are  similar  to  those  of  pleurisy  with  effu- 
sion, the  later  being  generally  unilateral,  however,  and 
hydrotliorax  bilateral.  For  this  reason  the  heart  is  not 
noticeably  displaced  in  hydrothorax,  unless  it  be  pushed 
dowm.  Hydrotliorax  is,  of  course,  unattended  by  fric- 
tion sounds. 

EMPYEMA. 

Empyema,  pyothorax,  or  suppurative  pleurisy,  is  a 
disease  characterized  by  pus  in  the  pleural  cavity.  It 
may  be  due  to  traumatism,  or  an  abscess  opening  into 
the  pleural  cavity  from  the  liver,  abdomen,  the  chest 
walls,  or  the  lung.  When  it  occurs  without  any  of 
these  causes  it  is  probably  due  to  some  constitutional 
vice  or  to  exhaustion  of  vitality.  But  why  j)leuritis 
should  sometimes  result  in  sero-fibrinous,  and  at  other 
times  in  purulent  effusion,  is  not  exactly  known. 

The  physical  signs  are  almost  identical  with  those  of 


154  PHYSICAL    DIAGNOSIS. 

pleurisy  with  non-purnlent  effusion.  There  is  usually 
more  emaciation  in  empyema,  and  the  signs  generally 
are  more  grave.  But  the  only  means  of  making  a  posi- 
tive diagnosis  is  by  withdrawing  some  of  the  fluid  with 
the  hypodermic  syringe,  or  other  aspirating  instrument. 

HEMOTHORAX. 

Hsemothorax,  or  blood  in  the  pleural  cavity,  may 
be  due  to  traumatic  causes,  or  it  may  result  from  cancer 
of  the  pleura  or  rupture  of  aneurism  into  the  pleural 
sac.  Very  rarely  it  is  caused  by  the  withdrawal  of 
fluid  from  the  pleural  cavity,  causing  rupture  of  vessels 
by  the  sudden  removal  of  the  pressure  to  which  they 
had  become  accustomed.  Wounding  the  intercostal 
artery  by  the  aspirating  needle  may  sometimes  produce 
it.  The  physical  signs  of  blood  in  the  pleural  cavity 
are  similar  to  those  of  pleurisy  with  effusion,  Neither 
in  hydrothorax  nor  hsemothorax  are  there  friction 
sounds.  The  former  is  usually  bilateral,  hsemothorax 
unilateral.  In  lijemothorax,  also,  the  symptoms  are 
sudden  and  urgent,  whereas  hydrothorax  is  always  in- 
sidious. 

PNEUMOTHORAX. 

Pneumothorax  is  a  disease  in  which  there  is  air  in 
the  pleural  cavity.  Generally  it  is  unilateral.  It  may 
be  due  to  traumatic  causes,  such  as  penetrating  wounds 
of  the  thorax,  injury  to  a  lung  from  the  end  of  a  fract- . 
ured  rib,  and  the  like.  Or  it  may  be  due  to  openings 
into  the  pleural  cavity  from  rupture  or  ulceration  of 
the  stomach  or  cpsophagus,  and  from  the  lungs  in  the 
course  of  empyema,  abscess,  or  hydatid  disease.    Ac- 


PNEUMOTHORAX.  1 5.5 

cording  to  Walshe,  however,  ninety  per  cent,  of  all 
cases  of  pneumothorax  are  caused  by  the  escax^e  of  air 
from  the  lungs  into  the  pleural  cavity,  due  to  breaking 
down  of  tubercle.  It  is  very  doubtful  if  gas  ever  orig- 
inates spontaneously  in  a  closed  pleural  cavity.  The 
physical  signs  are  as  follows: 

Inspection. —  Dyspnoea  and  anxious  countenance  are 
usually  noticeable.  Sometimes  there  is  more  or  less 
cyanosis.  Bulging  and  want  of  respiratory  movement 
on  the  affected  side  with  displacement  of  the  heart  in 
the  opposite  direction,  are  marked  in  proportion  to  the 
amount  of  air  in  the  pleural  cavity.  Respiratory 
movements  on  the  unaffected  side  are  exaggerated.  If 
the  opening  be  valvular,  so  that  air  enters  the  pleural 
sac  without  escaping,  the  dyspnoea  becomes  extreme, 
and  all  the  signs  are  marked. 

Palpation. — The  vocal  fremitus  is  diminished  or  ab- 
sent, according  to  the  amount  of  air  in  the  pleural  cav- 
ity. The  heart  may  be  felt  displaced  and  beating 
rapidly. 

Percussion. — Over  the  affected  side  there  is  tympani- 
tic resonance  on  percussion.  The  pitch  will  be  high  or 
low  according  to  the  volume  of  air  in  the  pleural  cav- 
ity and  the  tension  of  the  chest  walls.  Over  the  other 
lung,  exaggerated  resonance  is  due  to  the  extra  work  it 
is  doing,  and  the  state  of  vicarious  emphysema. 

Auscultation. — ^The  respiratory  murmur  over  the 
affected  side  is  usually  diminished  or  absent,  unless 
there  are  string-like  adhesions. 

The  vocal  resonance  is  also  diminished,  and  some- 
times, according  to  Walshe,  has  a  metallic  (amphoric) 
quality. 


156  rJIYSICAL    DIAGNOSIS. 

Tlie  tympanicity  on  percussion  at  once  distinguishes 
it  f I'oni  fluid  in  the  j^leural  cavity  from  any  cause.  The 
diagnosis  of  i^neumothorax  from  em]6hysema,  has  al- 
ready been  considered.     (See  Emphysema.) 

PNEUMO-HYDROTHORAX. 

Pneumo-hydrothorax,  or  hydro-j^neumothorax,  as 
the  name  indicates,  signifies  air  and  fluid  both  in  the 
pleural  cavity.  According  to  some  authors,  the  fluid 
is  always  purulent,  and  they  describe  it  as  pneumo- 
pyothorax,  or  pyo-pneumothorax. 

As  pneumothorax  is  always  followed  by  inflamma- 
tion tmd  effusion  into  the  i3leural  cavity  within  a  few 
hours,  or  a  day  or  two  at  most,  the  etiology  of  one  dis- 
ease applies  also  to  the  other. 

Iimpecthyn. — Dysj)n(pa  and  anxious  countenance, 
Avith  bulging  and  want  of  resj^iratory  movement  of  the 
affected  side  and  displacement  of  the  heart,  may  be 
noticed,  as  in  pneumothorax  or  pleurisy  with  effusion. 
If  the  opening  into  the  pleural  cavity  be  valvular,  so 
that  air  enters  more  readily  than  it  escapes,  the  signs 
are  more  marked.  Tliis  may  occur  at  different  times 
in  the  course  of  the  disease. 

Palijatio.h. — The  vocal  fremitus  is  diminished  or  ab- 
sent on  the  aff(M'ted  side.  The  heart  may  be  felt  out  of 
its  normal  position. 

Per6'W5.5/o??.— Above  the  level  of  the  fluid  the  note  is 
tympanitic,  as  in  pneumothorax.  Over  the  fluid  there 
is  marked  dullness  or  flatness,  as  in  pleurisy  with 
effusion  or  hydrothorax.  Not  infrequently  about  the 
union  of  the  two  there  is  amphoric  (jug,  metallic)  res- 
onance  on   percussion.     The  line  of  dullness  or  flat- 


PNEUMO-HYDROTHORAX. 


157 


ness  and  tympanicity,  changes  markedly  with  position 
of  the  patient.  In  these  cases,  also,  the  iipper  end  of 
the  iluid  is  horizontal,  instead  of  being  slightly  curved 
as  in  pleurisy  with  effusion. 

Auscultation. — The  respiratory  murmur  is  weakened 
or  absent,  or  else  it  is  amphoric  (jug,  metallic).     The 


Fig.  17. — Diagram  of  Pneumohydro-thorax,  showing  fluid  and  air  in  riglit  pleural 
cavitj',  right  lung  compressed  and  displacement  of  organs  to  the  opposite  side.  Also 
the  supposed  dropping  of  fluid. 

vocal  resonance  is  also  weakened,  or  sometimes  am- 
phorophony,  or  even  amphoriloquy,  may  be  present. 

BuGGUSsion. — This  is  the  act  of  shaking  the  patient 
wdiile  auscultating  at  the  same  time.  On  succussion 
the  splashing  sound  of  the  fluid  in  the  cavity  is  heard, 
often  by  the  patient  as  well  as  the  physician. 

Metallic  {amphoric,  jug)  tinkle  is  often  heard  in  this 
disease,  and  by  many  it  is  supposed  to  be  ]3roduced  by 


158  PHYSICAL    DIAGNOSIS. 

the  droiDping  of  fluid  from  above  into  the  fluid  below. 
It  may  be  x)ossible  that  in  such  a  large  cavity  as  is  usu- 
ally represented,  fluid  may  have  sufficient  distance  to 
fall  to  produce  the  sound;  but  even  here  it  is  more 
probably  due  to  the  bursting  of  bubbles  formed  by  in- 
spiration, or  by  shaking  the  patient.  The  distinctive 
sign  of  the  disease,  and  one  which  prevents  its  being 
mistaken  for  any  other,  is  the  splashing  sound  of  the 
fluid  in  the  cavity  heard  on  succussion.  It  is  impos- 
sible to  obtain  this  sound  in  simj)le  pleurisy  with  effu- 
sion, since  there  is  no  air  in  the  cavity,  and  hence  the 
fluid  there  cannot  be  shaken  any  more  than  it  could  be 
in  a  bottle,  or  other  vessel,  filled  up  to  the  cork.  In 
all  suspected  cases,  succussion  should  be  tried. 


CHAPTER  y. 

Summary  of  adventitious  sounds,  and  of  the  changes  in  the  nor- 
mal respiratory  murmur  and  vocal  resonance  produced  by 
disease. 

Adve]s^titious  sounds,  as  previonsly  stated,  are  wholly 
new  and  abnormal  sounds  ]Drodnced  by  disease,  and  are 
not  modified  normal  sounds.  They  have  been  variously 
divided  and  arranged  by  different  authors,  but  for 
simplicity  as  well  as  convenience  they  may  be  classified 
into  (1)  rales  or  rhonchi,  (2)  friction  sounds,  and  (3) 
splashing  sounds. 

I.  RIles. 

Rales,  or  rhonchi  (rattles),  have  also  been  grouped 
differently  by  different  authors,  but  they  may  be  re- 
duced to  three  varieties:  (1)  dry,  (2)  moist,  and  (3)  in- 
determinate. Each  of  these  varieties  will  now  be  con- 
sidered separately. 

1.  Dry  RIles. 

There  may  be  many  varieties  of  dry  rales,  but  two 
are  sufficient  to  include  them  all:  (1)  the  sonorous  and 
(2)  the  sibilant. 

Sonorous  Hales  are  loud,  low-pitched,  dry  rales, 
made  on  inspiration,  expiration,  or  both.  They  may 
be  produced  in  the  larynx,  trachea,  or  larger  bronchi. 
In  the  larynx  they  may  be  caused  by  si)asm  of  the 
glottis,  as  observed  in  laryngismus  stridulus,  croup,  and 


160  PHYSICAL    DIAGNOSIS. 

wliooping-cougli,  growths  within  the  larynx,  and  press- 
ure on  the  recurrent  larjTigeal  nerve  from  aneurism  or 
other  tumor.  In  the  trachea  they  may  be  due  to  press- 
ure without  from  some  tumor,  aneurism  for  examx)le, 
or  gTowths  within,  as  polypi,  or  oedema,  inflammatory 
exudation,  or  constriction  due  to  old  cicatrices  and 
the  like.  Such  rales  are  termed  stridor,  and  the  breath- 
ing is  said  to  be  stridulous.  If  the  pressure,  or  ob- 
struction, or  constriction,  be  sufficiently  marked,  sibi- 
lant as  well  as  sonorous  rales  may  be  produced  f  n  these 
localities.  These  rales  made  in  the  larynx  or  trachea 
are,  however,  conveyed  all  over  the  chest  usually,  and 
should  be  differentiated  by  means  of  the  stethoscope ; 
an  easy  matter,  as  they  are  much  louder  at  the  site  of 
their  production  than  elsewhere  Sonorous  rales  are 
made  iii  the  larger  bronchi  from  narrowing  of  their 
calibre  by  external  pressure  from  some  tumor,  strict- 
ure due  to  old  inflammation,  spasm  of  the  muscular 
coats,  or  tumefaction  of  the  lining  mucous  membrane, 
or  else  ("he  vibration  of  viscid  mucus  within  the  tubes. 
These  rales  are  generally  transient,  and  change  on 
coughing.  For  this  reason,  it  would  appear  that  they 
are  more  frequently  due  to  varying  spasm  oi-  vibrating 
mucus  that  is  removed  by  coughing.  Where  the  cause 
is  permanent,  the  rales  are  few  in  number,  and  often 
changeable,  though  less  so,  showing  that  even  in  these 
cases,  ^dbrating  mucus,  from  localized  irritation,  is  often 
an  important  factor.  Both  sonorous  and  sibilant  rales 
are  heard,  especially  in  the  early  or  dry  stage  of  bron- 
chitis and  in  spasmodic  asthma.  In  the  latter  disease 
they  are  also  sometimes  said  to  be  mewing  and  chiri^ing. 
Sibilant  rales  are  high  pitched,  whistling,  dry  rales, 


MOIST    RALKS.  161 

made  on  inspiration,  expiration,  or  both.  As  already 
remarked,  they  may  be  made  in  the  larynx  or  trachea, 
if  the  calibre  be  diminished  sufficiently.  For  the  same 
reason  they  may  also  be  made  in  the  larger  bronchi. 
Usually,  however,  they  are  made  in  the  smaller  bronchi. 
The  causes  of  their  production  are  the  same  as  for  the 
sonorous  or  snoring  rales,  and,  like  them,  are  heard  es- 


PiG.  18. — Sonorous  and  Sibilant  Rales.    SnE,  riouorous  Rales  ;  SbR,  Sibilant  Rales. 

pecially  in  the  dry  stage  of  bronchitis,  and  in  an  attack 
of  asthma.  They  are  also  changeable,  being  heard 
more  distinctly  now  in  one  place  and  then  in  another. 

2.  Moist  Rales. 
These  may  occur  in  the  larynx,  trachea,  bronchi,  air- 
cells,  or  in  the  pleural  cavities.    Laryngeal  and  tracheal 
rales  may  also  be  moist  as  well  as  dry.     Moist  tracheal 

rales  occurring  just  before  death,  as  they  often  do,  are 
11 


162  PHYSICAL    DIAGNOSIS. 

commonly  called  death  rattles.  These  rales  may  also 
be  heard  over  the  chest,  and  their  locality  should  be 
differentiated  by  means  of  the  stethoscope.  In  cases 
where  rales  of  any  kind  are  heard  over  the  chest,  the 
patient  should  be  directed  to  clear  the  throat,  so  as  to 
get  rid,  if  possible,  of  any  laryngeal  or  tracheal  rales 
that  might  exist. 

Many  varieties  of  moist  rales  occurring  in  the  bron- 
chi are  described  by  various  authors,  but  three  are  suffi- 
cient to  include  them  all:  (1)  mucous,  (2)  submucous, 
and  (3)  subcrepitant. 

Mucous  rales  are  large,  moist,  bubbling  rales  made 
in  the  larger  bronchi,  and  are  heard  both  on  inspira- 
tion and  expiration,  since  the  tidal  air  acts  on  the  fluid 
in  the  tubes  both  on  entering  and  leaving  them.  These 
rales  are  usually  attended  with  expectoration,  and  they 
change  about  on  coughing.  Fluid  of  any  sort  in  the 
larger  bronchial  tubes  will  give  rise  to  mucous  rales, 
whether  it  be  mucus,  blood,  or  pus.  We  therefore  find 
them  in  such  diseases  as  bronchitis,  unless  the  secretion 
be  very  scant,  certain  cases  of  pulmonary  hemorrhage, 
abscess,  and  pulmonary  consumption.  In  general  bron- 
chitis the  rales  are  bilateral,  but  usually  few  in  number. 
If  not  heard  at  all  on  first  listening,  they  may  be  de- 
veloped by  coughing.  In  other  diseases  where  the 
bronchitis  would  be  local,  the  rales  would  also  be  lo- 
calized. 

Submucous  rales  are  moist,  bubbling  rales,  rather- 
smaller  than  the  mucous,  and  are  made  in  the  medium- 
sized  bronchi.     They  are  also  heard  both  on  inspiration 
and  expiration,  are  attended  with  expectoration,  and 
are  changed  by  coughing.     They  are  produced  in  the 


MOIST  RALES.  163 

same  way,  and  are  due  to  the  same  causes,  as  the  mu- 
cous rales  (see  fig.  8,  p.  38). 

8itbcrepitant  rales,  or  muco-crepitant  rales,  are  the 
finest  moist  bronchial  rales,  and  are  made  in  the  finer 
(ultimate)  bronchial  tubes,  chiefly  on  inspiration,  and  are 
not  as  easily  changed  as  the  mucous  and  submucous 
by  coughing.  This  is  accounted  for  by  the  fact  that  in- 
spiration is  a  greater  force  than  expiration,  as  affecting 
the  finer  tubes  and  air-cells.  Hence  the  mucus  in  these 
localities  is  overcome  with  greater  force  on  inspiration 
than  expiration,  and  the  subcrepitant  rales  are  conse- 
quently produced  on  inspiration  rather  than  expira- 
tion. They  may  be,  and  often  are,  entirely  wanting 
during  expiration.  Instead  of  being  caused  by  the 
bursting  of  very  fine  bubbles,  these  rales  are  sometimes 
caused  by  the  forcible  separation  of  agglutinated  tube 
walls,  and  then  they  are  invariably  heard  only  on  in- 
spiration. In  capillary  bronchitis  they  are  heard  on 
both  sides,  usually  posteriorly  and  low  down.  In  pul- 
monary oedema  they  are  also  sometimes  heard  as  the 
serous  fluid  enters  the  tubes  (see  (Edema).  The  rale 
also  occurs  in  the  third  stage  of  lobar  pneumonia,  due 
to  secondary  local  bronchitis  and  liquefying  exudation. 
In  pulmonary  hemorrhage  from  any  cause  these  rales 
are  produced  if  blood  enters  the  finer  tubes,  and  hence 
are  often  heard  in  hemorrhagic  infarction.  Pus  in 
these  finer  tubes  also  gives  rise  to  it,  whether  the  pus 
be  due  to  purulent  bronchitis,  rupture  of  an  abscess, 
or  perforation  from  empyema.  This  rale  is  also  the 
adventitious  sound  usually  heard  in  the  first  stage  of 
phthisis,  although  it  may  evidently  occur  in  any  stage. 

Crepitant  rales  are  made  in  the  air-cells,  and  are  the 


164  PHYSICAL    DIAGNOSIS.- 

only  vesicular  rales  that  exist.  They  are  very  fine, 
uniform,  crackling  rales,  heard  only  at  the  (tip)  end  of 
inspiration,  and  are  anchanged  by  coiighing.  They 
are  caused  by  the  forcible  separation  of  agglutinated 
cell  walls,  as  in  the  first  stage  of  lobar  pneumonia,  or 
agitation  of  thin  fluid  in  the  air-cells,  as  in  pulmonary 
a?dema.  They  are  heard  also  in  the  third  or  resolving 
stage  of  lobar  imeumonia,  where  it  is  known  as  the 
rale  redux,  or  rale  that  has  returned,  or  come  back. 
The  crej)itant  rale,  then,  and  not  the  subcrepitant,  as 
is  so  often  erroneously  stated,  is  the  rale  redux,  or  re- 
turned rale.  The  subcrepitant  rale  is  not  a  j)^i't  of 
the  physical  signs  of  any  stage  of  pneumonia  but  the 
third,  in  which  it  has  not  come  back,  but  is  heard  for 
the  first  time.  The  crepitant  rale,  however,  which  was 
heard  in  the  first  stage',  and  lost  in  the  second  after  the 
air-cells  had  become  obliterated,  now  comes  back,  or  is 
redux,  in  the  third  stage.  The  crepitant  rales  heard 
in  pulmonary  oedema  are  louder  and  more  liquid  in 
quality  than  those  of  pneumonia.  The  crepitant  rale 
may  also  be  heard  in  pulmonary  consumption  in  any 
stage,  if  the  conditions  for  its  production  exist,  and 
other  adventitious  sounds,  usually  present,  are  not 
so  loud  as  to  obscure  it. 

Mucous  Cliclx. — A  single  fine,  high-pitched  moist 
click  that  is  usually  unchanged  by  cough,  may  be  heard 
at  or  near  the  end  of  inspiration  over  incomplete  consol- 
idation in  the  first  stage  of  i^hthisis.  As  Loomis  says,^ 
it  sounds  like  an  isolated  subcrepitant  rale.  When  it  is 
really  of  mucous  origin,  it  is  no  doubt  due  to  the  sud- 
den passage  of  air  through  a  fine  bronchial  tube  ob- 
structed by  pressure  without,  due  to  tubercle,  for  in- 


MOIST  rIlES.  lOo 

stance,  or  viscid  mucus  within.  It  is  a  very  important 
adventitious  sound  in  the  commencement  of  pulmo- 
nary consumption.  But  may  it  not  sometimes  also  be 
of  pleuritic  origin? 

Gurgles  are  moist,  bubbling  rales  made  in  a  cavity, 
and  are  large  or  small,  or  low  and  high  pitched,  accord- 
ing to  the  size  of  the  cavity  and  amount  of  consolidated 
tissue  intervening.  They  are  made  either  during  in- 
spiration or  expiration,  but  inasmiich  as  the  air  usu- 
ally enters  a  cavity  with  more  force  than  it  leaves,  gur- 
gles are  consequently  apt  to  be  louder  on  insi3iration 
than  expiration.  Sometimes  they  are  heard  only  on 
insj)iration.  Moreover,  during  inspiration,  the  direc- 
tion of  the  current  is  toward  the  ear  of  the  listener,  in- 
stead of  from  it,  as  in  expiration.  If  the  cavity  be  full 
of  fluid  there  may  be  no  gurgles.  None  will  be  heard, 
also,  if  the  cavity  be  empty,  or  if  the  opening  into  it  be 
such  as  to  prevent  fluid  from  being  agitated  by  the  air 
entering  or  leaving  it.  If  the  opening  into  the  cavity 
becomes  stopped  with  a  plug  of  viscid  mucus,  a  clot 
of  blood,  or  other  material,  gurgles  which  were  heard 
before  now  immediately  cease.  On  coughing  and  re- 
moving the  obstruction  they  at  once  return.  (See  col- 
ored jjlate  showing  cavity.) 

Metallic  Tinkle,  or  Amfplioric  Tiiikle. — If  the  cavity, 
whether  it  be  ]Dulmona,ry  or  intra-pleural,  have  hard, 
smooth  walls,  and  be  of  sufficient  size  to  act  as  a  reso- 
nant chamber,  in  other  words,  if  it  be  an  amphoric  cav- 
ity, and  if  it  contain  a  small  amount  of  viscid  fluid 
with  the  tube  opening  under  it  or  into  it,  so  as  to  pro- 
duce explosion  of  bubbles,  metallic,  or  am^Dhoric  tinkle 
is  apt  to  result.     Or  it  may  be  produced  by  the  vibra- 


166  PHYSICAL    DIAGNOSIS. 

tion  of  viscid  mucus.  It  is  usually  heard  most  dis- 
tinctly on  inspiration,  like  ordinary  gurgles,  and  is  not 
constant.  It  often  disappears  on  coughing,  or  it  may 
be  developed  by  coughing.  According  to  Walshe,  such 
adventitious  sound  need  not  be  situated  in  the  cavity 
at  all,  if  it  be  near  enough  so  that  the  sound  shall  be 
echoed  in  the  cavity.  Metallic  tinkle  is  also  sometimes 
produced  by  sjieaking  or  coughing.  It  is  probably 
never  due  to  dropping  of  iluid  in  a  pulmonary  cavity, 
since  there  could  hardly  be  distance  enough  for  it  to 
fall  with  sound  sufficiently  distinct  to  be  heard.  Even 
in  pneumo-hydrothorax,  metallic  tinkle  may  be  re- 
garded as  a  musical  rale  of  amphoric  quality,  j)roduced 
by  the  bursting  of  bubbles  rather  than  the  dropping 
of  fluid.  For  that  reason  it  has  been  classified  with 
the  moist  rales. 

Intra-pleural  Moist  Bales. — Pleuritic  friction  sounds 
are  easily  distinguished  from  other  adventitious  sounds ; 
but  occasionally  we  hear  sounds,  evidently  of  intra- 
pleural origin,  that  exactly  imitate  moist  bronchial  or 
vesicular  rales.  Some  authors  go  so  far  as  to  say  that 
the  crepitant,  as  well  as  the  subcrepitant  rale,  is  al- 
ways intra-pleural.  In  the  same  way  other  intra- 
pleural adventitious  sounds,  resembling  mucous  and 
submucous  rales,  are  sometimes  heard,  so  that,  as  Da 
Costa  says,  no  human  ear  can  tell  the  difference  by  the 
quality  alone.  How  are  we  to  distinguish  between 
them?  This  subject  has  already  been  alluded  to  (see 
Bronchitis).  If  the  rales  are  localized,  unilateral, 
unchanged  by  coughing,  jDeripheral  and  superficial, 
and  unattended  with  expectoration,  they  are  usually 
intra-pleural.     If,  on  the  other  hand,  they  are  bilateral, 


INTRAPLEURAL   rIlES.  167 

changed  by  cough,  attended  with  more  or  less  expecto- 
ration, deep-seated,  and  generally  distributed  over  the 
chest,  they  are  almost  surely  bronchial.  But  how  can 
we  distinguish  the  crepitant  rale  made  in  the  air-cells 
from  the  intra -pleural  crex)itation  ?  Sometimes  it  is 
difficult  or  even  impossible.  This,  however,  does  not 
necessarily  make  the  two  identical  any  more,  for  in- 
stance, than  it  makes  thoracic  aneurism  and  pleurisy 
with  effusion  identical,  because  one  has  been  mistaken 
for  the  other  until  i^ost-mortem  examination  revealed 
the  true  state  of  the  case.  In  pulmonary  oedema  we 
have  the  crepitant  rale  bilateral  and  low  down  poste- 
riorly. There  is  also  watery  expectoration  and  the 
cause  of  oedema  (see  CEdema).  Intra-pleural  crepitation 
is  rarely  bilateral,  and  then  is  unattended  with  expec- 
toration, unless  there  be  complication.  In  the  first  and 
third  stages  of  lobar  pneumonia  it  is  more  difficult  to 
say  that  the  rale  is  not  intra-pleural.  Even  in  these 
cases  the  rale  sometimes  follows  the  outline  of  the 
lobe  too  closely  to  say  that  it  is  always  intra-pleural. 

Intra-j^leural  moist  rales  do  not  require  actual  in- 
flammation of  the  pleurae  for  their  production.  Per- 
verted nutrition  of  the  membrane  from  any  cause  may 
give  rise  to  a  viscid,  glutinous  secretion,  instead  of  the 
normal  lubricating  material,  so  that  the  pleurae,  in- 
stead of  gliding  noiselessly  on  each  other  during  respi- 
ration, will  produce  sounds  which,  as  already  stated, 
may  be,  and  often  are,  identical  in  quality  with  vesicu- 
lar, bronchial,  tracheal,  or  laryngeal  moist  rales. 


108 


PHYSICAL    DIAGNOSIS. 


3.    IlSTDETERMIXATE    RaLES. 

Indeterminate  rales  include  all  other  rales  not  em- 
braced in  the  foregoing  classes  and  varieties.  They  are 
crackling  and  crumpling  sounds,  partly  moist  and 
partly  dry,  produced  on  inspiration  or  expiration,  or 
both,  and  it  is  impossible  to  determine  with  certainty 
whether  they  are  of  intra-pleural,  pulmonary,  or  bron- 
chial origin.  Flint  states  that  they  are  found  usually 
early  in  phthisis.  They  may  be  heard  during  any 
stage,  but  particularly,  perhaps,  after  the  disease  has 
advanced  sufficiently  to  give  rise  to  broken-down  tissue 
and  complicated  pathological  conditions.  The  follow- 
ing table  in  regard  to  rales  may  be  of  use : 


1.  Dry  Rales. 


Rales  or 
Rhonchi.  ■{ 
'6  classes 


2.  Moist  Rales. 


Indetermi- 
nate Rales. 


Stridor— produced  in  the  Larynx. 
Sonoi'ous — produced  in    the    Large 

Bronchi. 
Sibilant  —  produced    in  the    Small 

Bronchi. 

'  Laryngeal — produced  in  theLarynx. 

Tracheal— produced  in  the  Trachea. 

Mucous  —  produced  in  the  Large 
Bronchi. 

Submucous — produced  in  the  Medi- 
um Sized  Bronchi. 

Subcrei^itant  —  produced  in  the 
Small  Bronchi. 

Crepitant — jn-oduced  in  the  Air-cells 
or  vesicles. 

Mucous  Click — produced  in  a  Small 
Bronchus. 

Gurgles — produced  in  Cavities  (pul- 
monary). 

Metallic  (amphoric)  Tinkle  —  pro- 
duced in  Cavities 

Interi)leural  moist  rales  which  may 
simulate  any  of  the  above  moist 
rales. 

Partly  moist,  jiartly  dry,  crackling 
and  crumpling  sounds,  whose 
exact  origin  and  mode  of  pro- 
duction are  unknown. 


FRICTION    SOUNDS — SPLASHING   SOUNDS.  1G9 

II.  Friction"  Sounds. 

Friction  sounds  are  due  to  pleuritic  inflammation. 
Their  true  patliological  signiUcance  was  tirst  pointed 
out  about  1819  by  Honore,  of  Paris,  a  contemporary 
of  Laennec.  The  membrane,  which  in  health  was 
moistened  with  a  lubricating  secretion,  so  that  the  two 
opposite  layers  glided  noiselessly  upon  each  other  dur- 
ing respiration,  now  becomes  dry  and  rough,  or  agglu- 
tinated. For  this  reason,  grazing,  rubbing,  rasping, 
grating,  rumbling,  or  creaking  sounds  may  be  pro- 
duced. The  sounds  are  heard  chiefly  on  inspiration, 
and  are  usually  interrupted,  so  that  several  may  occur, 
during  one  inspiration.  They  are  also  heard  sometimes 
during  expiration.  As  already  stated,  pleuritic  friction 
sounds  are  heard  more  distinctly  usually  on  inspira- 
tion than  expiration  (p.  140).  As  Flint  correctly  states, 
these  sounds  are  usually  more  distinctly  heard  after 
removal  of  the  fluid,  if  any  exist,  than  before,  as  the 
surfaces  of  the  i:»leurfe  are  by  that  time  more  roughened 
than  at  flrst.  These  friction  sounds  are  of  variable 
duration,  depending  upon  the  pathological  condition. 
When  well  marked,  esjoecially  in  those  having  thin 
chest  walls,  friction  fremitus  may  be  felt  on  palj)ation. 

III.  Splashing  Sounds. 

Succussion  is  the  act  by  which  sx^lashing  sounds  are 
produced.  It  consists  in  shaking  the  patient  while  the 
ear  is  placed  to  the  chest.  By  this  means  the  splash- 
ing of  fluid  in  a  cavity  containing  air  and  fluid  is  heard, 
as  in  pneumo-hydrothorax  (or  xmeumo-pyothorax).  It 
might  be  iDossible,  also,  in  a  large  pulmonary  ca\i.ty 


170  PHYSICAL    DIAGNOSIS. 

containing    air    and    fluid.     It    is   usually,   however, 
pathognomonic  of  pneumo-hydro  (or  pyo)  thorax. 

CHANGES  IN  THE  RESPIRATORY  MURMUR. 

I.  Changes  of  Intensity. 

The  sound  of  the  respiratory  murmur,  as  well  as  of 
the  voice,  arrives  at  the  chest  walls  in  health,  first, 
through  convection  along  the  tubes,  and  secondly,  re- 
fraction (diffusion)  in  the  air-cells.  But  for  this  refract- 
ing power  of  the  healthy  lungs,  due  to  the  presence  of 
the  air-cells,  the  intensity  of  the  resj)iratory  murmur 
and  of  the  voice  sounds  would  be  greatly  increased,  as 
-occurs  in  solidification.  On  the  other  hand,  the  sounds 
would  be  diminished  or  absent,  according  to  the  amount 
of  obstruction  in  the  tubes  to  convection,  increased  re- 
fraction, as  in  emphysema,  and  interruption,  as  in  pleu- 
ritic thickening  or  effusion. 

We  see,  then,  that  these,  as  well  as  other  sounds  on 
their  way  to  the  chest  walls,  may,  according  to  the  con- 
ditions present,  be  subjected  to  (1)  convection,  (2)  ob- 
struction, (8)  refraction  (diffusion),  (4)  conduction,  and 
(5)  interruption.  On  the  chest  walls,  or  along  strings 
of  adhesion,  they  may  be  transmitted,  or  extended. 

In  health,  then,  when  convection  along  the  tubes  is 
perfect,  and  there  is  only  normal  refraction  (diffusion) 
in  the  air-cells,  we  hear  the  normal  respiratory  murmur, 
Avhicli  will  be  laryngeal,  tracheal,  bronchial,  vesiculo- 
bronchial, or  vesicular,  according  to  the  locality. 

The  intensity  of  this  murmur  A\ill  be  weakened  or 
suppressed  (also  termed  diminished  or  absent);  (1)  in 
proportion  to  obstruction  to  convection  in  the  tubes, 
•either  from  growths,  nuicus,  ims,  blood,  or  other  ob- 


CHANGES   IN   THE   KESPIKATORY   MURMUR.         171 

stacles  within,  or  stricture,  from  old  infiammation  or 
compression  of  the  tubes  from  aneurism,  cancer,  hyda- 
tids, or  some  other  cause ;  (2)  increased  refracting  (dif- 
fusing) power  in  the  lungs,  due  to  dilatation  of  the  air- 
cells,  as  in  chronic  general  emphysema;  or  (3)  inter- 
ruption from  pleuritic  thickening  or  effusion.  Second- 
arily, it  would  be  modified  also  by  interference  with 
the  proper  expansion  of  the  lungs  and  chest  walls  from 
pain,  pleuritic  adhesions,  and  deformities. 

The  intensity  may  be  slightly  increased  (exaggerated) 
in  two  ways.  First,  without  any  change  in  quality  or 
rhythm,  as  when  one  lung  or  part  of  a  lung  is  tempo- 
rarily mcariously  emphysematous  from  doing  extra 
work,  owing  to  crippling  of  the  other  lung  or  part  of  a 
lung.  It  is  simply  louder  than  normal,  and  is  sometimes 
termed  hyper-vesicular  or  supplementary.  It  differs 
somewhat  from  puerile  breathing,  which  is  heard  in 
children  under  the  age  of  xouberty,  whose  lungs  are  not 
develoi:)ed  in  proportion  to  their  bronchial  tubes.  Both 
are  loud  (rude),  but  the  puerile  respiratory  murmur 
has  more  of  a  bronchial  element  in  it.  N'either  are 
necessarily  harsh  (rough),  this  quality  depending  on 
the  roughness  of  the  mucous  membrane  lining  the 
larger  bronchial  tubes,  and  caused  by  the  friction  of 
the  tidal  air 

Secondly,  it  may  be  slightly  increased  (exaggerated), 
with  change  in  the  quality  and  rhythm,  as  seen  in  the 
vesiculo-bronchial  breathing,  due  to  incomplete  consol- 
idation with  corresponding  increase  of  conduction,  and 
diminution  of  refraction,  in  the  lungs,  owing  to  oblit- 
eration, in  part,  of  some  air-cells;  as  seen  in  the  first 
stage  of  phthisis  pulmonalis. 


172  PHYSICAL   DIAGNOSIS. 

The  intensity  of  the  murmur  will  be  markedly  in- 
creased if  refraction  is  replaced  by  conduction ;  in  other 
Avords,  if  the  air-cells  are  replaced  by  solidified  lung 
tissue,  as  occurs,  for  instance,  in  the  second  stage  of 
lobar  pneumonia,  which  offers  a  homogeneous  medium 
for  the  conduction  of  sound. 

II.  Rhythm. 

Prolonged  expiration  and  divided  respiration  are  the 
two  principal  changes  in  the  rhythm.  In  the  normal 
vesicular  respiratory  murmur,  inspiration  is  about  four 
times  longer  than  expiration,  and  the  two  are  continu- 
ous. Moreover,  expiration  is  lower  in  pitch  than  in- 
spiration. Now,  in  a  paroxysm  of  asthma,  and  in 
chronic  emj^hysema,  the  expiration  is  prolonged,  but 
is  not  usually  changed  in  pitch  or  quality.  In  a  par- 
oxysm of  asthma  the  expiration  is  not  only  prolonged, 
but  inspiration  is  much  shortened  by  being  deferred, 
that  is  to  say,  it  is  not  heard  in  the  commencement. 
The  rhythm  in  such  a  paroxysm  is  Just  the  reverse  of 
what  it  is  in  health,  that  is  to  say,  expiration  is  four 
times  longer  than  inspiration,  or  even  longer.  In  em- 
physema, expiration  is  also  prolonged  and  inspiration 
deferred,  but  it  is  never  observed  that  expiration  is 
four  times  longer  than  inspiration,  unless  there  be 
also  marked  obstruction  to  the  exit  of  air  from  the 
presence  of  mucus,  or  other  cause.  In  bronchitis,  also, 
expiration  is  prolonged  in  proportion  to  the  obstruction 
from  mucus,  especially  in  capillary  bronchitis;  but  the 
respiratory  murmur  is  not  otherwise  changed,  unless 
in  some  cases  it  may  become  harsh  or  rough  (see 
Changes  in  Quality).     In  asthma  and  bronchitis,  the 


RHYTHM.  173 

expiration  is  prolonged,  because  of  obstruction  to  the 
egress  of  air,  either  from  spasm  of  the  muscular  coats 
of  the  tubes,  or  mucus  within  the  tubes,  or  tumefaction 
of  the  bronchial  mucous  membrane.  In  general  em- 
physema, on  the  other  hand,  expiration  is  prolonged 
on  account  of  the  rigid  dilatation  of  the  thorax,  caused 
by  loss  of  resiliency  of  lung  tissue,  rigidity  of  the  cos- 
tal cartilages,  and  crippling  of  the  diaphragm,  leaving 
the  muscular  coats  of  the  bronchial  tubes  to  perform 
the  act.  If  obstruction  in  the  tubes,  due  to  co-existing 
bronchitis,  also  is  well  marked,  the  expiration  will  be 
still  more  prolonged,  but  usually  the  expiration  of  em- 
physema is  not  so  much  prolonged  as  to  be  four  times 
the  length  of  inspiration,  as  in  a  paroxysm  of  asthma, 
where  obstruction  is  marked  on  account  of  spasm  as 
well  as  mucus  and  tumefaction.  The  reason  for  pro- 
longed expiration  in  such  cases  has  already  been  fully 
explained  (see  Asthma). 

In  consolidation  of  lung  tissue,  expiration  is  also 
prolonged,  but  the  murmur  in  these  cases  differs  from 
those  just  mentioned  by  having  the  i)itch  always  raised, 
on  account  of  its  passing  from  one  medium  to  a  denser 
medium,  with  shorter  vibrations  and  the  quality 
changed.  Instead  of  being  blowing  in  quality,  it  is 
more  or  less  tubular.  The  prolongation  is  not  due  so 
much  to  the  criiDpling  of  the  expiratory  forces,  or  to 
obstruction  to  the  egress  of  air,  as  it  is  to  the  fact  that 
the  incomi)letely  or  completely  solidified  lung  tissue, 
being  a  better  conducting  medium,  enables  one  to  hear 
the  murmur  more  distinctly  and  for  a  greater  length 
of  time. 

The  respiratoiy  munnur  may  be  divided — that  is, 


174  PHYSICAL   DIAGNOSIS. 

the  inspiration  and  expiration  may  not  be  continuons. 
This  is  usually,  if  not  always,  due  to  consolidation  to  a 
certain  degree.  In  case  of  incomplete  consolidation, 
inspiration  and  expiration  are  not  continuous,  by  insiDi- 
ration  being  unfinished.  The  gap  between  the  two  will 
be  marked  in  proportion  to  the  extent  and  complete- 
ness of  consolidated  tissue.  When  a  whole  lobe  is 
consolidated,  as  in  the  second  stage  of  lobar  pneumo- 
nia, for  instance,  the  break  between  inspiration  and 
expiration  is  well  marked. 

Wavy,  jerky,  or  cog- wheeled  respiratory  murmur  is 
sometimes  heard  in  the  first  stage  of  phthisis.  It  is 
usually  attributed  to  the  sudden  overcoming  of  strict- 
ure or  obstruction  in  a  bronchial  tube,  from  pressure 
of  tubercle,  or  mucus  within.  This,  however,  is  doubt- 
ful, since  it  is  often  heard  in  perfectly  healthy  chests 
of  those  who  are  nervous,  hysterical,  or  have  palpitation. 
It  is  more  often  due  to  ^palpitation  of  the  heart  than  any- 
thing else,  and  is  oftener  heard  in  women  than  men. 
Taken  by  itself  as  a  physical  sign  of  disease  of  the 
lungs,  it  is  worthless.  It  is  usually  heard  on  inspira- 
tion, but  may  also  be  heard  on  expiration,  or  both. 

III.  Quality. 

Besides  being  changed  in  intensity  and  rhythm,  the 
respiratory  murmur  may  also  be  changed  in  quality. 
Instead  of  its  being  jDurely  vesicular  in  quality,  as 
heard  over  the  left  subclavicular  region,  it  may  become . 
vesiculo-bronchial.  The  late  Dr.  Austin  Flint  termed 
it  broncho-vesicular,  but,  as  Da  Costa  suggests,  the 
order  of  occurrence,  as  actually  heard,  being  first  vesi- 
cular and  then  bronchial,  it  is  more  correct  to  call  it 


QUALITr.  175 

vesiculo-bronchial.  It  was  formerly,  and  is  now  by 
some,  termed  rude  (loud)  respiration.  Others,  again, 
call  it  harsh  or  rough.  Neither  of  these  terms  is  de- 
scriptive of  the  true  condition,  nor  is  the  murmur  neces- 
sarily harsh,  rough,  or  even  rude.  A  resiDiratory  mur- 
mur is  harsh  or  rough  if  the  mucous  membrane  of  the 
larger  tubes  is  in  a  harsh  or  rough  condition,  so  that 
the  tidal  air,  by  friction  against  it,  in  i)assing  in  and 
out,  has  the  quality  of  harshness  or  roughness  imparted 
to  it.  For  this  reason,  any  respiratory  murmur,  exclud- 
ing the  purely  normal  vesicular,  may  be  harsh  or  rough. 

In  vesiculo-bronchial  breathing,  expiration  is  pro- 
longed, raised  in  pitch,  and  more  or  less  tubular  in 
quality,  in  proportion  to  obliteration  of  air-cells,  by 
which  the  vesicular  element  is  lessened,  as  in  incom- 
plete consolidation  from  some  cause,  or  proximity  to 
bronchial  tubes.  For  the  latter  cause,  we  obtain  a  nor- 
mal vesiculo-bronchial  breathing  in  the  right  sub- 
clavicular region  of  a  healthy  chest.  Vesiculo-bron- 
chial breathing  is  also  among  the  early  signs  of 
phthisis,  while  consolidation  is  incomplete. 

Bronchial  breathing  is  significant  of  com^Dlete  con- 
solidation of  lung  tissue,  as  in  the  second  stage  of 
lobar  pneumonia.  Here  all  vesicular  quality  is  lost, 
and  both  inspiration  and  expiration  become  tubular  in 
quality.  Expiration  is  as  long  as  inspiration,  or  longer; 
the  pitch  of  both  is  raised,  expiration  being  usually 
higher  than  inspiration,  and  the  intensity  is  greatly 
increased  in  the  sense,  not  of  volume,  but  concentrated 
amount.  It  sounds  somewhat  like  blowing  across  the 
mouth  of  the  stethoscope.  It  may  be  imitated  by  put- 
ting a  piece  of  liver  in  a  tin,  or  other  tube,  covering 


176  PHYSICAL    DIAGNOSIS. 

both  ends  witli  a  tliin  membrane,  and  then  listening 
through  it  to  tracheal  respiration.  Over  a  cavity  we 
usually  hear  cavernous  breathing,  wliich  is  blowing  in 
quality,  giving  the  idea,  as  Flint  states,  of  air  passing 
in  and  out  of  a  hollow  space.  It  differs  from  bronchial 
breathing  by  being  usually  low  pitched  and  blo\\dng  in 
quality,  whereas  bronchial  breathing  is  necessarily 
high  pitched,  the  sound  of  the  murmur  having  ];)assed 
from  one  medium  to  a  denser  medium,  and  tubular  in 
quality.  Both  are  more  intense  than  the  normal  re- 
spiratory murmur,  but  cavernous  breathing  is  more  in- 
tense in  the  sense  of  volume,  bronchial  breathing  in 
concentrated  amount. 

When  consolidated  lung  tissue  is  extensive  near  a 
cavity,  there  is  sometimes  heard  a  mixture  of  cavern- 
ous and  bronchial  qualities,  or  the  caverno-bronchial 
breathing.  Flint  was  the  first  to  describe  this  kind  of 
respiratory  murmur,  and  termed  it  broncho-cavernous. 
In  nearly  all  the  cases  cavernous  quality  comes  first, 
and  is  followed  by  the  bronchial,  though  there  is  no 
reason  why  this  should  always  be  so.  For  this  reason, 
however,  it  is  termed  caverno-bronchial,  rather  than 
broncho-cavernous. 

Should  the  cavity  be  large,  situated  near  the  apex, 
and  have  hard,  smooth  walls,  a  free  oi)ening  communi- 
cating with  a  bronchial  tube,  and  not  contain  much 
fluid,  amphoric  respiration,  or  jug-breathing,  may  be 
heard.  It  sounds  like  blowing  into  the  mouth  of  an 
empty  jug  (amphora)  or  bottle.  The  pitch  of  this 
breath  sound  will  vary  with  the  size  of  the  cavity,  its 
mouth  and  other  conditions,  but  it  is  by  its  quality, 
not  pitch,  that  it  is  distinguished. 


PECTOROPHONY.  177 

CHANGES  IN  THE   PECTOROPHONY  OR  VOCAL   RESO- 
NANCE. 

The  sounds  of  the  patient's  voice,  as  heard  over  the 
larynx,  trachea,  or  any  part  of  the  chest  walls  by  the 
auscultator,  may  be  divided  into  two  classes:  (1)  that 
in  which  only  the  voice  is  heard,  and  (2)  when  speech 
or  articulation  is  heard.  To  the  first  class  the  termina- 
tion ophony  {phonos,  voice)  is  applied,  to  the  latter, 
iloquy  (speech).  The  sound  of  the  voice,  therefore,  as 
normally  heard  over  the  larynx,  is  termed  normal 
laryngophony,  and  over  the  trachea,  normal  tracheoph- 
ony  or  trachophony.  As  the  speech  is  oftener  heard  in 
these  localities  than  the  voice  simply,  so  do  we  more 
frequently  hear  normal  laryngiloquy  and  normal  tra- 
chiloquy  over  these  organs. 

I.  Pectoeophont. 

Pectorophony,  or  chest  voice,  is  the  sound  of  the 
voice,  or  the  vocal  resonance,  heard  over  the  chest, 
without  our  being  able  to  distinguish  the  articulate 
words  as  spoken  by  the  patient. 

Normal  pectorophony,  or  normal  vocal  resonance,  as 
it  is  more  commonly  called,  when  heard  over  pul- 
monary vesicular  tissue,  is  a  distant,  diffused,  indis- 
tinct, buzzing  sound,  with  a  somewhat  low  pitch,  cor- 
responding to  the  pitch  of  the  patient's  voice.  A 
low-pitched,  loud,  harsh  voice,  other  things  equal, 
yields  more  intense  pectorophony  than  a  highq^itched, 
weak  voice,  in  the  sense  of  volume.  For  this  reason, 
men  usually  have  normally  more  intense  pectorophony 

than  women,  and  grown  people  of  both  sexes  than 
12 


178  PHYSICAL    DIAGNOSIS. 

children.     Thin  chest  walls,  other  things  equal,  also 
favor  the  production  of  pectorophony. 

Diminislied  ijectoroijliony^  or  weakened  vocal  reso- 
nance, occurs  in  those  cases  where  there  is  obstruction 
in  the  bronchi  to  the  convection  (conveyance)  of  the 
voice  sound,  as  in  bronchitis  with  abundant  mucous 
secretion,  j^us  or  blood,  polypi,  stricture  of  the  bron- 
chi, from  old  inflammation,  or  their  compression  from 
some  cause,  as  cancer,  aneurism,  hydatids,  and  other 
tumors.  Also  when  there  is  increased  refractive  poAver 
of  the  lungs,  as  in  chronic  general  emphysema,  with 
permanent  dilatation  of  the  aii-cells,  or  when  there  is 
interrui)tion  to  the  transmission  of  the  voice  from 
pleuritic  thickening  or  effusion.  In  some  of  these 
cases,  whispering  pectorophony  may  be  entirely  absent 
or  suppressed.  In  general,  the  same  conditions  for 
weakening  or  suppressing  the  respiratory  murmur 
apj)ly  to  the  whisj^ered  voice. 

Exaggerated  ^pectorophony^  or  exaggerated  vocal 
resonance,  occurs  when  the  intensity  is  increased  from 
any  cause.  It  is  heard  normally  in  the  right  sub- 
clavicular region,  on  account  of  proximity  to  the  right 
bronchial  tube,  as  already  stated.  But  it  is  also  heard 
over  incomplete  solidification  of  lung  tissue,  owing  to 
the  better  conducting  power  of  the  latter.  It  is  there- 
fore one  of  the  early  signs  of  incipient  phthisis.  Under 
these  conditions,  the  sound  of  the  voice  is  nearer,  less 
diffused,  and  more  distinct  and  intense,  in  the  sense, 
of  concentrated  amount. 

Bronchial  pectorophony,  bronchophony,  or  bron- 
chial voice,  is  heard  when  all  vesicuhir  quality  is  lost, 
owing  to  comjjlete  solidification  of  lung  tissue.     The 


PECTOROPHONY.  179 

voice  sound  comes  to  the  ear  of  the  auscultator  directly 
from  the  bronchial  tubes,  through  the  solidified  lung 
tissue.  It  is  near,  concentrated,  and  distinct,  or  the 
very  ox)j)osite  of  normal  pectorophony  (vocal  reso- 
nance). The  pitch  of  bronchophony  is  necessarily 
high,  owing  to  the  transition  of  the  sound  from  one 
medium  to  a  denser  medium. 

In  some  instances,  bronchophony,  instead  of  being 
near  and  strong,  sounds  as  if  it  were  distant  and  weak. 
Weak  or  distant  bronchophony  is  caused  by  the  inter- 
vention usually  of  pleuritic  thickening  or  effusion. 
Obstruction  to  convection  in  the  bronchi  from  com- 
pression, or  stricture,  or  a  plug  of  viscid  mucus,  might 
cause  bronchophony  to  be  weakened  or  ■  even  sup- 
pressed. 

JEgo2ohony,  so  named  from  its  resemblance  to  the 
bleating  of  a  goat,  is  bronchophony  made  tremulous 
by  vibrating  fluid  in  the  pleural  cavity  usually,  though 
it  may  occur  in  some  rare  cases  of  pulmonary  cavities 
and  other  disease.  It  is  more  of  a  clinical  curiosity 
now  than  it  is  of  any  real  value,  since,  in  cases  of  doubt 
and  necessity,  the  aspirating  needle  may  be  used  to 
determine  the  presence  of  fluid.  Besides  being  tremu- 
lous, gegophony  is  more  or  less  weakened  by  the  pleuri- 
tic conditions  present.  It  also  usually  possesses  a  nasal 
quality  for  some  reason. 

Cavernous  voice,  or  cavernopliony,  is  heard  when 
listening  over  a  cavity.  It  differs  from  bronchophony, 
for  while  the  latter  is  high-pitched  and  tubular  in 
quality,  with  an  increased  intensity  in  the  sense  of 
concentrated    amount,    cavernophony    is    often    low 


180  PHYSICAL    DIAGNOSIS. 

pitched,  sepulchral  in  quality,  and  has  its  intensity 
increased  in  the  sense  of  volume. 

Amphoric  tioice,  or  ampltorophony  (Jug  voice),  is 
simply  cavernoi)hony  possessing  the  quality  of  am- 
phoricity,  and  resembles  the  sound  of  the  voice  in  an 
empty  jug  or  other  vessel.  It  has  a  peculiar  ringing, 
metallic,  or  amphoric  quality,  and  may  be  attended, 
like  the  breathing,  or  the  cough,  by  amphoric,  or  me- 
tallic echo.  The  terms  amphoric  and  metallic  are  used 
to  convey  the  same  idea,  the  former  referring  to  the 
particular  kind  of  cavity,  the  latter  to  the  material, 
which  imparts  the  quality  to  sounds.  Should  the 
patient  whisper  instead  of  speaking  out  loud,  as  was 
first  recommended  by  the  late  Dr.  Austin  Flint,  we 
would  have  some  variety  of  whispering  pectorophony. 
In  some  cases,  it  might  be  absent  or  suppressed;  in 
others,  exaggerated,  and  then  Flint  termed  it  exagger- 
ated bronchial  ^^'hisper.  In  the  same  way  we  would 
have  whispering  bronchophony,  cavernous  whisper  or 
whispering  cavernophony,  and  amphoric  whisper  or 
whispering  amphorophony.  The  following  table  gives 
a  summary  of  the  voice  sounds: 

Laryiigophony 
Tracheophony 

'  Normal  Pectorophony,  or  vocal  resonance. 
Diminished  or  weak  (tlie  whisper  may  be 

absent  or  suppressed). 
Exa{?s*^rated  (slifj^htly  increased). 
Pectorophony -J  Bronchophony — bronchial  voice  (may  be 
weak). 
iEgopliony — goat's  voice  (tremulous). 
Cavernophony — cavernous  voice. 
Amphorophony — amphoric  (jug)  voice. 

II.  Pectoriloquy. 
Pectoriloquy,  or  chest  speech,  is  the  speech  (articu- 
late words)  of  the  p;iti<mt  as  heard  through  the  chest 


PECTORILOQUY.  181 

walls  by  tlie  aiiscultator.  The  term  was  first  used  by 
Laeunec,  of  Paris,  about  1820,  and  always  had  reference 
to  cavities,  since  it  was  thought  that  only  over  cavities 
could  the  articulate  words  of  the  i^atient  be  heard.  It 
is,  however,  quite  evident  that  pectoriloquy  may  be 
obtained  in  other  conditions  than  cavities.  It  is  some- 
times heard  over  perfectly  healthy  chests,  especially 
among  those  who  have  thin  chest  walls  and  a  loud  re- 
spiratory murmur,  as  among  some  women  and  chil- 
dren. It  is  quite  often  heard  over  the  larynx  and 
trachea,  normally. 

Bronchial  Pectoriloquy,  or  BroncTiiloquy. — Instead 
of  bronchophony  simply,  we  sometimes  also  hear  the 
articulate  words  of  the  patient  over  consolidated  lung 
tissue.  Indeed,  Guttmann  states  that  there  is  no  dif- 
ference between  bronchophony  and  pectoriloquy.  But 
as  bronchophony  differs  from  cavernophony,  both 
being  pectorophony,  so  does  bronchial  pectoriloquy,  or 
bronchiloquy,  differ  from  cavernous  pectoriloquy  or 
caverniloquy,  the  former  being  necessarily  high-pitched, 
the  latter  usually  low-pitched.  In  case  of  whispered 
voice,  the  former  is  also  tubular  in  quality,  the  latter 
blowing.  The  intensity  of  the  former  is  also  increased 
in  concentrated  amount,  the  latter  in  volume. 

Cavernous  pectoriloquy,  or  caverniloquy,  is  the 
speech  of  the  patient  as  heard  over  an  ordinary  cavity. 
As  Flint  truly  remarks,  one  must  not  expect  to  be  able 
to  carry  on  a  conversation  with  his  patient  through  a 
cavity,  but  if  some  syllables  of  some  simple  phrase  or 
words,  as  one,  two,  three,  be  heard,  it  is  sufficient  to 
establish  pectoriloquy  of  any  variety. 

Amphoric  pectoriloquy,  or  amphoriloquy,  is  the 


182  PHYSICAL   DIAGNOSIS. 

speech  of  the  patient  with  an  amphoric  or  metallic  in- 
tonation, as  if  speaking  in  the  mouth  of  an  empty  jug. 
It  is  significant  of  amphoric  cavity.  If  the  patient 
whispers  instead  of  speaking  out  loud,  we  then  hear 
whispering  laryngiloquy,  trachiloquy,  or  pectoriloquy, 
of  whatever  variety  the  latter  may  be.  The  following 
table  gives  a  summary  of  varieties  of  speech  (articulate 
voice)  sounds: 

Laryngiloquy. 
Trachiloquy. 

C  Normal  Pectoriloquy. 
Bronchiloquy — Bronchial  speech  (may  be  weak 
Pectoriloquy  \  or  tremulous). 

Caverniloquy — Cavernous  speech, 
t  Amphoriloquy — Amphoric  speech. 


CHAPTER  YL 

THE   HEART. 

The  Heart  is  a  hollow  organ  of  striated  or  voluntary 
muscnlar  tissue,  but  so  presided  over  by  the  sympa- 
thetic nervous  system  that  its  movements  are,  with 
very  rare  exceptions,  wholly  involuntary.  Only  in  ex- 
tremely rare  cases  has  the  individual  been  able  to  cause 
the  heart  to  beat  fast  or  slow  at  will.  The  fact  that  it  is 
of  the  striated  or  voluntary  muscular  tissue  is  of  great 
importance  in  connection  with  certain  dynamic  cardiac 
murmurs,  to  be  described  hereafter.  IS'ormally,  the 
heart  is  conical  in  sha^De,  and,  in  the  adult,  five  inches 
long,  three  and  a  half  inches  broad  and  two  and  a  half 
inches  thick.  It  weighs  from  ten  to  twelve  ounces  in 
men,  and  in  women  from  eight  to  ten  ounces. 

The  heart  is  obliquely  situated  within  the  thorax, 
between  the  lungs,  and  is  inclosed  by  the  pericardium. 
The  base,  directed  upward  and  backward  to  the  right, 
is  on  a  level  with  the  upper  borders  of  the  thu^d  costal 
cartilages,  extending  half  an  inch  to  the  right,  and  one 
inch  to  the  left  of  the  sternum ;  the  apex,  forward  and 
downward  to  the  left,  corresponds  to  a  point  between 
the  fifth  and  sixth  costal  cartilages  (fifth  intercostal 
space),  two  inches  below  and  one  inch  within  the  left 
nipple,  according  to  Gray.  According  to  others,  it  is 
an  inch  and  a  half  below,  and  half  an  inch  within,  the 
left  nipple,  and  this  is  probably  more  nearly  correct. 


184  PHYSICAL   DIAGNOSIS. 

According  to  Flint,  the  apex  of  the  heart  in  health 
should  fall  a  little  within  the  mammillary  line.  Of 
course  these  rules  apply  only  to  those  cases  where  the 
nipple  is  in  its  normal  position,  for  sometimes  it  is  dis- 
placed by  deformity,  or  large  size  of  the  gland,  as  in 
nursing  women  or  those  who  have  borne  children.  The 
force  of  the  normal  apex-beat  differs  in  different  cases. 
In  some  it  is  perceptible  on  insx)ection,  in  others  not, 
and  in  some  cases  it  may  not  even  be  felt  on  palpation. 
This  is  accounted  for  chiefly  by  difference  in  the  thick- 
ness of  the  chest  w^alls  and  size  of  the  ribs.  Among 
those  having  thick  chest  walls  with  wide  ribs,  the  im- 
pulse of  the  heart  will  not  usually  be  so  percei)tible  as 
among  those  who  have  thin  chest  walls  and  narrow 
ribs  with  correspondingly  wide  intercostal  spaces.  The 
normal  heart  beats  more  forcibly  in  some  persons  than 
others,  and  the  impulse  also  differs  somewhat  with 
position  of  the  body. 

Outline  of  the  Heart. — The  base  corresponds  to  a 
line  drawn  across  the  sternum  along  the  upper  borders 
of  the  third  costal  cartilages,  extending  half  an  inch  to 
the  right  and  one  inch  to  the  left  of  the  sternum.  A 
line  so  drawn  is  termed  the  base  line  of  the  heart.  The 
left  border  corresponds  to  a  line  curving  outward,  but 
within  the  left  nipi)le,  from  the  left  end  of  the  base 
line,  down  to  tlie  apex.  This  border  is  .formed  by  the 
left  ventricle.  The  right  border  of  the  heart  consists 
of  a  light  border  proper,  formed  partly  by  the  right 
auricle,  and  partly  by  the  right  ventricle,  and  a  lower 
border  formed  chiefly  by  the  right  ventricle.  Draw  a 
line  from  the  ai)ex  horizontally  to  the  median  line  of 
the   sternum,  to   correspond   with   the   lower  border, 


THE  Up; ART.  185 

thence  curving  upward  and  slightly  outward  to  the 
right  end  of  the  base  line,  to  form  the  right  border 
proper. 

Areas  of  Cardiac  Dullness. — Auscultatory  j)ercus- 
sion  (p.  33)  is  the  best  method  for  accurately  mapx)ing 
out  the  limits  of  the  heart,  the  patient  being  in  the 
erect  position,  unless  one  has  no  assistant,  and  then  the 
recumbent  position  is  best.  There  are  two  areas  of 
dullness,  the  deep  and  superficial.  The  whole  area  of 
dullness,  including  the  deep  and  superficial,  extends 
vertically  from  the  upper  borders  of  the  third  costal 
cartilages  to  the  upper  border  of  the  sixth,  and  trans- 
versely from  a  point  a  little  within  the  left  nipx^le  to 
about  half  an  inch  to  the  right  of  the  sternum. 

The  deeiD  area  of  dullness  corresponds  to  that  portion 
of  the  heart  covered  up  by  lung  tissue,  and  is  increased 
with  enlargement  of  the  heart  from  any  cause. 

The  superficial  area  of  dullness  is  somewhat  triangu- 
lar in  shape,  with  little  lung  tissue  over  it.  This  area 
is  bounded  below  by  a  line  drawn  horizontally  from  the 
apex  to  the  median  line  of  the  sternum ;  on  the  right, 
by  the  median  line  of  the  sternum  up  to  the  level  of 
the  upper  borders  of  the  fourth  costal  cartilages ;  and 
on  the  left,  by  a  line  drawn  from  the  last-named  point 
to  the  apex.  This  last  line  curves  outward,  but  falls 
within  the  left  nij)ple.  The  sui^erficial  area  of  dullness 
is  diminished  at  the  end  of  a  full  inspiration  and  in  em- 
physema; it  is  increased  by  ventricular  enlargements 
and  pericardial  effusion.  It  is  formed  by  the  right 
ventricle,  except  at  the  aj^ex,  which  is  composed  of  the 
left  ventricle.  This  latter  fact  is  very  important  in 
connection  with  murmurs  made  within  the  left  ventricle. 


186 


PHYSICAL    DIAGIN^OSIS. 


The  Circulation. — The  heart  is  divided  lengthwise 
into  right  and  left,  or  venous,  and  arterial  halves,  and 
these  two  are  divided  crosswise,  so  as  to  form  two 
upper  and  two  lower  compartments — four  in  all — the 
two  upper  compartments  being  the  right  and  left  auri- 
cles respectively,  and  the  two  lower  being  the  right 


Fig.  19. — Normal  Blood  Currents  in  the  Heart  and  Relative  Position  of  the  Ventri- 
cles, Auricles  and  Great  Vessels.  IVC,  Inf.  Vena  Cava;  HVC,  Sup.  Vena  Cava;  RA, 
Rt.  Auricle;  TV,  Tricusiiid  Valves;  RV,  Kt.  Ventricle;  P,  Pulmonary  Valves;  PA, 
Pulmonary  Artery;  Pv.  Pulmonary  Veins;  LA,  Left  Auricle;  MV.  Mitral  Valves; 
LV,  Left  Ventricle;  A,  Aortic  Valves;  Aa,  Arch  of  Aorta. 

and  left  ventricles.  The  right  (or  venous)  side  of  the 
heart  is  situated  in  front  of,  slightly  above  and  to  the 
right  of  the  left  side,  so  that  in  looking  at  the  normally 
situated  heart,  from  the  front,  w- e  see  the  right  ventricle 
and  right  auricle,  and  only  a  small  part  of  the  left  auri- 
cle, and  a  narrow  strij)  of  the  left  ventricle,  which  ex- 
tends down  further  than  tlie  right  ventricle,  and  forms 
tlie  apex. 


PLATE    VI. 


Schematic  Diagram,  representing 
the  Normal  Blood  Currents  in  the 
Heart— A  VC,  Ascending  Vena  Cava; 
D  V  C,  Descending  Vena  Cava;  R  A, 
Right  Auricle;  T  V,  Tricuspid  Valves; 
R  V,  Right  Ventricle;  P,  Pulmonary 
Valves;  P  v,  Pulmonary  Veins;  L  A, 
Left  Auricle;  M  V,  Mitral  Valves;  L  V, 
Left  Ventricle. 

A,  Aortic  Valves;  A  a,  Arch  of  Aorta. 


ORAWH     BY  H.M*COONALO     M.D.N.Y. 


THE  hp:akt.  187 

The  j)ulmonary  artery  is  about  two  inches  long,  and 
arises  from  the  left  side  of  the  base  of  the  right  ventri- 
cle, in  front  of  the  aorta,  at  a  point  corresponding  to 
the  junction  of  the  left  third  costal  cartilage  with  the 
sternum.  The  left  auricle  lies  deeply  behind  it.  It 
ascends  obliquely  upward  and  outward  across  the  sec- 
ond left  intercostal  space  near  the  sternum,  and  divides 
under  the  arch  of  the  aorta,  behind  the  second  left  cos- 
tal cartilage,  into  a  right  and  left  branch,  one  for  each 
lung.  The  second  left  intercostal  sjDace  is  also  called, 
therefore,  the  pulmonary  (pulmonic)  interspace.  The 
pulmonary  artery  carries  venous  blood  from  the  right 
ventricle  into  the  lungs. 

The  aorta  arises  from  the  upper  part  of  the  left  ven- 
tricle behind,  and  a  little  below,  the  origin  of  the  pul- 
monary artery,  at  a  point  on  a  level  with  the  lower 
border  of  the  left  third  costal  cartilage,  just  behind  the 
left  edge  of  the  sternum.  It  passes  obliquely  upward 
to  the  right,  a  little  beyond  the  right  edge  of  the  ster- 
num, in  the  right  second  intercostal  si)ace,  to  the  upper 
border  of  the  right  second  costo-sternal  articulation. 
A  needle  passed  through  the  second  intercostal  space 
close  to  the  right  edge  of  the  sternum  would,  after 
passing  through  the  lung,  enter  the  pericardium  and 
the  most  prominent  j)art  of  the  bulge  of  the  aorta 
(Gray).  This  second  intercostal  space  on  the  right  side 
of  the  sternum  is  therefore  also  called  the  aortic  inter- 
space. The  venous  blood,  emptying  into  the  right 
auricle  from  the  superior  and  inferior  vense  cavse, 
passes  through  the  tricuspid  orifice,  into  the  right  ven- 
tricle. The  direction  of  the  blood  at  first  is  toward  the 
apex,  but  it  suddenly  curves  upward  to  the  left,  and  is 


188  PHYSICAL    DIAGNOSIS. 

driven  by  ventricular  systole  through  the  pulmonary 
orifice,  and  by  the  iiulmonary  artery  it  is  conveyed  into 
the  lungs,  for  aeration.  From  the  lungs  the  aerated 
(arterial)  blood  is  conveyed  by  the  j)ulmonary  veins  to 
the  left  auricle.  Thence  through  the  mitral  orifice  into 
the  left  ventricle.  Here  the  blood  current,  as  in  the 
right  ventricle,  is  directed  at  first  toward  the  apex,  but 
immediately  curves  u^^ward  to  the  right,  to  the  aortic 
opening,  through  which  it  is  driven  by  ventricular  sys- 
tole. Closure  of  the  mitral  and  tricuspid  valves  occurs 
Avith  ventricular  systole,  and  prevents  regurgitation 
from  the  ventricles  into  the  auricles ;  and  closure  of  the 
semilunar  (sigmoid)  valves  guarding  the  pulmonary 
and  aortic  orifices  occurs  with  ventricular  diastole 
(arterial  systole),  to  prevent  regurgitation  from  the 
arteries  into  the  ventricles. 

Situation  of  the  Valves. — The  pulmonary  valves  are 
situated  highest  up  in  the  thorax  of  any  of  the  valves 
of  the  heart.  A  needle  pushed  through  the  centre  of 
junction  of  the  left  third  costal  cartilage  with  the  ster- 
num, would  penetrate  about  the  centre  of  the  ^^ulmo- 
nary  orifice.  We  do  not,  how^ever,  listen  directly  over 
this  point  for  sounds  connected  with  the  pulmonary 
orifice  in  their  loudest  intensity,  for  the  bone  inter- 
venes ;  but  we  listen  in  the  second  left,  or  j)ulmonary 
(pulmonic),  interspace,  where  the  sounds  are  conveyed. 

The  aortic  valves  are  situated  behind  the  pulmonary, 
a  little  lower  down  and  to  the  right,  just  behind  the~ 
left  edge  of  the  sternum  on  a  level  with  the  lower  bor- 
der of  the  third  rib.  We  do  not  listen  here  through 
the  bone  for  Jiortic  sounds,  but  in  the  second  right,  or 
aortic,  interspace  where  they  are  conveyed. 


THE  HEART. 


189 


The  mitral  valves  guarding  the  orifice  between  the 
left  auricle  and  left  ventricle,  are  situated  deeply 
within,  at  a  point  corresponding  with  the  upper  border 
of  the  left  fourth  costal  cartilage,  near  the  left  edge  of 
the  sternum.  We  do  not  listen  here  for  sounds  con- 
nected with  the  mitral  orifice,  for  the  right  ventricle  and 


Fig.  20. — Diagram  showing  Location  of  the  Valves  of  the  Heart,  and  Points  of 
Maximum  Intensity  of  Sounds  connected  with  them.  The  triangle  a6  c  is  the  area 
of  superficial  dullness. 

pulmonary  tissue  are  in  front  of  it ;  but  we  listen  down 
at  the  apex,  which  is  made  of  the  left  ventricle,  and 
to  this  point  mitral,  as  well  as  other  left  ventricular, 
sounds  are  conveyed. 

Lastly,  the  tricuspid  valves  are  situated  behind  the 
median  line  of  the  sternum,  between  the  fourth  costo- 
sternal  articulations.     But  we  do  not  listen  at  this 


190  PHYSICAL    DIAGT^OSIS. 

point  for  tricuspid  sounds,  but  itt  the  point  where  the 
lower  border  of  the  right  ventricle  crosses  the  sternum, 
about  the  base  of  the  ensiform  cartilage.  The  tricus- 
pid valves  guard  the  orifice  between  the  right  auricle 
and  right  ventricle. 

A  circle  of  one  inch  in  diameter  includes  parts  of  all 
the  valves  of  the  healthy  heart,  but  of  course  they  are 
not  in  the  same  plane,  those  of  the  left  side  of  the  heart 
being  behind  the  right.  It  is  very  important  to  ob- 
serve, also,  that  we  do  not,  as  a  rule,  listen  directly 
over  the  orifices  and  their  valves  in  order  to  best  hear 
sounds  connected  with  them,  but  over  those  points  to 
which  such  sounds  are  conveyed  with  greatest  intensity, 
as  follows :  for  pulmonary  sounds,  over  the  pulmonary 
(second  left)  interspace;  for  aortic  sounds,  over  the 
aortic  (second  right)  interspace ;  for  mitral  sounds,  over 
the  apex ;  and  for  tricusjud  sounds,  over  the  ensiform 
cartilage.  Posteriorly,  however,  we  do  listen  over  the 
location  of  the  mitral  valves  for  the  mitral  regurgitant 
murmur,  as  will  be  fully  described,  as  will  also  be  the 
areas  of  transmission  of  various  sounds. 

Sounds  of  the  Heart. — There  are  two  sounds  of  the 
heart — first  and  second.  As  the  first  sound  is  heard 
loudest  at  the  apex,  it  is  also  called  the  apex  or  inferior 
sound  of  the  heart ;  and  because  it  occurs  during  sys- 
tole it  is  also  called  the  systolic  sound.  The  second 
sound  is  best  heard  at  the  base,  and  hence  is  sometimes 
called  the  basic  or  superior  sound  of  the  heart,  and  be-, 
cause  it  occurs  in  diastole  it  is  also  called  the  diastolic 
sound. 

The  first  sound  (inferior,  apex,  systolic)  of  the  heart 
is  a  composite  sound,  partly  due  to  closure  of  the  mi- 


THE  HEART.  191 

tral  and  tricuspid  valves,  and  i)artly  due  to  tlie  apex- 
beat,  the  rush  of  blood,  and  the  stretching  of  the 
chordae  tendinese,  to  say  nothing  of  other  elements. 
But  whatever  elements  take  part  in  its  production,  it 
is  necessary,  and  very  important,  to  know  and  remem- 
ber that  the  first  sound  in  the  normal  heart  is  synchro- 
nous with  (occurs  at  the  same  time  with)  the  closure 
of  the  mitral  and  tricuspid  valves,  the  systole  of  the 
ventricles,  and  the  apex-beat.  The  latter  slightly  pre- 
cedes, of  course,  the  radial  pulse.  This  first  sound, 
though  heard  almost  at  any  part  of  the  chest  in 
some  cases,  is  best  heard  in  all  at  the  apex,  as  already 
stated,  and  sounds  like  lib^  in  the  words  tub  or  rub. 
But  it  does  not  sound  like  rub  or  lub^  except  when 
there  is  a  prsesystolic  murmur,  as  we  shall  see.  Tt  is 
longer  in  duration  and  lower  pitched  than  the  second 
sound. 

Tlie  second  sound  (superior,  basic,  diastolic)  of  the 
heart,  is  produced  by  the  simultaneous  closure  of  the 
semilunar  (sigmoid)  valves  of  the  aortic  and  pulmonary 
orifices,  and  is  synchronous  with  diastole  of  the  ventri- 
cles. It  is  heard  best  at  the  base  of  the  heart,  and  is  a 
shorter,  sharper,  and  higher-i:)itched  sound  than  the 
first,  and  resembles  the  word  up^  in  cup. 

lihythm  of  the  heart  is  the  repetition  of  all  the  suc- 
cessive phenomena  which  go  to  make  up  what  is  termed 
a  complete  circuit  or  revolution,  each  one  of  which  is 
divided  into  a  first  sound,  first  rest,  second  sound,  and 
second  rest. 

Suppose  a  revolution  to  be  ten-eighths  of  an  inch 
long:  the  first  sound  would  be,  according  to  Walshe, 
four-eighths  (half -inch),  the  first  rest  one-eighth,  the 


192  PHYSICAL    DIAGNOSIS. 

second  sound  two-eighths  (quarter  of  an  inch),  and  the 
second  rest  three-eighths  of  an  inch  long,  thus: 

ub            clup 
Apex  | 1  •  | \ |; 

up             tup 
Base  | 1  •  1 1    •  •  •  | 

Fig.  21.— Normal  Rhj-thm  of  the  Heart  as  heard  at  the  Apex  and  Base. 

The  heart's  rhythm  may  be  imitated  by  striking  a 
table,  for  instance,  with  the  palmar  surface  of  the  hand, 
near  the  wrist,  for  the  first  sound,  and  with  the  point 
of  the  finger  for  the  second,  observing  the  i^roper  inter- 
vals for  the  periods  of  silence.  In  the  accompanying 
diagram  the  consonants  d  and  t  are  xjlaced  before  the 
second  sound,  as  heard  at  the  apex  and  base  respect- 
ively, merely  for  the  sake  of  eux)hony,  and  not  because 
there  are  really  any  such  elements  of  sound  in  the  nor- 
mal rhythm  of  the  heart. 


Fig.  22.— Sphj-gmographic  Tracing— Normal  Heart.    (Walshe.) 

We  now  proceed  to  consider  the  heart  in  its  various 
abnormal  conditions. 

Yalvt^lar  Lesioxs  of  the  Heart. 

A'alvular  lesions  commonly  give  rise  to  enlargement 
of  the  heart.  They  usually  result  from  one  or  more 
previous  attacks  of  endocarditis.  The  latter  disease 
frequently  occurs  in  the  course  of  acute  articular  rheu- 
matism, especially  among  the  young,  but  it  may  also 
occur  during  an  attack  of  diphtheria,  scarlet  fever,  ty- 
X^hoid  fever,  measles,  s>T[)hilis,  lead  poisoning,  gout, 


PLATE   VII. 


R.A 


Fig.  A 


R.V. 

Normal  Heart. 


FiG.B. 


Mitral  Regurgitation-  showing 

enlar9ement  of  LA.LV   &  RV. 


FiG.C, 


FiG.D. 


LA. 


R.V. 


R.A 


L.V. 


R.V. 


Mitral  Obstruction.-  Showing  Aortic  Obstruction  &  Regurgitation. 

enlaraement  of  LA  8f  RV.  Showing  enlargement  of  LV. 

REFERENCE. 

■R.A.  Right  Auricle.  R.V.  Right  Ventricle. 

LA.  Left    -'<-  L.V.  Lejt       -"- 


DRAWH    BY  H.MACDONALD    M.D.  N.Y. 


VALVULAR   LESIOXS    OF   THE   HEART.  193 

erysipelas,  Bright's  disease  of  the  kidneys,  and  other 
diseases,  or  it  may  be  due  to  pyemia,  or  surgical  in- 
jury, or,  finally,  it  may  occur  independently.  In  the 
latter  case  it  is  termed  idiopathic  endocarditis.  Such 
cases  are,  however,  very  rare.  Valvular  lesions,  es- 
pecially aortic  insufficiency,  may  also  be  due  simply 
to  violence,  as  in  lifting.  Endocarditis  during  foetal 
life  attacks  the  right  side  of  the  heart,  because,  in  that 
state,  the  right  side  of  the  heart  has  more  work  to  do 
than  the  left.  For  the  same  reason  endocarditis  attacks 
the  left  side  of  the  heart  after  birth.  It  is  extremely 
improbable,  that,  as  Richardson,  of  London,  states,  the 
blood  receives  a  poison  in  the  lungs  after  birth,  which 
it  takes  directly  to  the  left  heart,  causing  endocarditis 
of  the  left  side  of  the  heart ;  but  by  the  time  it  gets 
back  to  the  right  heart,  the  poison  has  lost  its  virulence. 
If  it  be  due  to  poison  only,  the  right  heart  should  be 
poisoned  instead  of  the  left,  for  the  blood  is  supposed 
to  be  purified  in  the  lungs,  instead  of  being  poisoned 
there.  Endocarditis  does  not  necessarily  leave  traces 
behind,  but  it  usually  does.  It  may,  however,  affect 
the  valves  or  orifices,  or,  they  remaining  intact,  it  may 
leave  some  lesional  traces  on  the  wall  within  the  ven- 
tricle at  some  point,  or  ^ooints. 

From  what  has  been  said  of  foetal  endocarditis,  we 
conclude  that  children  with  valvular  lesions  of  the  tri- 
cuspid or  pulmonary  valves  were  born  with  them, 
though  they  may  not  have  been  discovered  for  several 
years  afterward,  when  the  changes  in  the  heart  pro- 
duced would  make  the  signs  more  observable.  But 
relative  (or  secondary)  insufficiency  of  the  tricuspid 

valves  occurs  in  persons  after  they  are  born.     This  is 
13 


194  PHYSICAL    DIAGNOSIS. 

due,  not  to  inflammation,  but  to  enlargement  of  the 
riglit  ventricle  (dilated  liypertropliy)  as  in  general  em- 
physema, and  mitral  obstruction  or  regurgitation, 
where,  owing  to  the  dilated  hypertrophy  of  the  right 
ventricle,  the  tricuspid  valves  presently  fail  to  close 
the  orifice,  on  account  of  their  being  mechanically  sep- 
arated too  widely. 

Order  of  Frequency  of  Valmtlar  Lesions. —  All 
agree  that  mitral  regurgitation  is  the  most  common. 
Regarding  mitral  obstruction  authors  disagree.  Dr. 
Walshe  i^laces  it  last  of  the  valvular  lesions  in  the  left 
heart,  but  I  am  disposed  to  think  it  is  often  present 
with  regurgitation.  The  following  is  the  order  of  fre- 
quency, according  to  Dr.  Walshe : 

(1)  Mitral  regurgitation,  (2)  aortic  obstruction,  (3) 
aortic  regurgitation,  (4)  mitral  obstruction,  (5)  tricus- 
pid regurgitation  (relative  included),  (6)  pulmonarj^ 
obstruction  (most  frequent  inflammatory  of  the  right 
heart),  (7)  pulmonary  regurgitation  (very  rare),  and  (8) 
tricuspid  obstruction  (hardly  known).  I,  myself,  have 
never  observed  a  case  of  pulmonary  regurgitation,  and 
tricuspid  obstruction  is,  probably,  only  recognizable  on 
post-mortem,  examination,  if  it  should  ever  occur. 

Valvular  lesions,  instead  of  existing  singly,  may  be, 
and  often  are,  combined. 

Order  of  Frequency  of  Combinations. — According 
to  Walshe  they  are  as  follows : 

(1)  Mitral  regurgitation  and  aortic  obstruction,  both 
giving  rise  to  systolic  murmurs.  (2)  Aortic  obstruction 
and  regurgitation.  (3)  Mitral  regurgitation  and  aortic 
regurgitation.  (4)  Mitral  regurgitation,  aortic  obstruc- 
tion and  regurgitation.     (5)  Mitral  obstruction  and  re- 


CARDIAC    MURMURS.  195 

gurgitation,  and  so  on.  From  the  foregoing,  it  will  be 
observed  that  obstruction  and  regurgitation  may,  and 
do,  exist  at  the  same  orifice.  This  is  jDerfectly  true,  for 
while  the  orifice  may  be  constricted,  the  valves  may  be 
prevented  from  closing  by  being  fixed  oi)en  by  adhesion. 
As  already  mentioned,  in  a  general  way,  valvular  le- 
sions usually  produce  enlargement  of  the  heart.  It 
may  now  be  further  stated  that  each  valvular  lesion  is 
followed  by  enlargement,  peculiar  to  itself.  This  is  of 
the  greatest  im^Dortance  in  making  a  diagnosis,  and 
should  never  be  lost  sight  of  by  the  examiner.  In 
speaking  of  enlargement,  also,  not  only  is  dilatation,  or 
hypertrophy,  meant,  but  both— dilated  hypertrophy, 
or  hypertrophous  dilatation. 

Now  as  to  whether  dilatation  occurs  first  and  hyper- 
trophy afterward,  authors  again  disagree.  It  seems 
reasonable  that  the  two  should  proceed  together,  until 
the  time  arrives  when  hypertrophy  ceases.  Then  un- 
compensated dilatation  alone  remains.  Tliat  is  the 
usual,  inevitable  tendency,  if  the  patient  lives  long 
enough  and  does  not  die  meantime  of  some  complica- 
tion or  fatal  intercurrent  disease. 

The  particular  enlargements  (hypertrophous  dilata- 
tions, or  dilated  hypertrophies)  following  the  various 
lesions  respectively,  will  be  considered  with  each  case 
of  valvular  disease. 

Caediac  Murmues. 

Cardiac  murmurs  are  adventitious  sounds  heard  in 
connection  with  the  heart  in  addition  to,  or  in  the  ]3lace 
of,  those  sounds  that  exist  in  health.  When  due  to 
organic   disease   they   are   termed   organic   murmurs. 


19G  PHYSICAL   DIAGNOSIS. 

But  when  due  to  anaemia  or  perverted  cardiac  action 
they  are  said  to  be  inorganic,  or  simply  functional. 
Either  of  these  two  classes  of  murmurs  may  originate 
without  or  within  the  heart,  the  former  being  termed 
pericardial  (exocardial),  the  latter  endocardial  mur- 
murs.   They  may  also  exist  together  or  separately. 

Endocardial  Murmurs. 

Valvular  lesions  usually  give  rise  to  enlargement  of 
the  heart,  and  are  generally  accompanied  by  permanent 
murmurs.  The  latter  assist  greatly  in  making  a  correct 
diagnosis  in  each  case,  according  to  their  location,  areas 
of  conduction  and  transmission,  and  also  by  their 
rhythm  or  time  of  occurrence  with  regard  to  the  sounds 
of  the  heart.  The  properties,  or  elements,  of  mui^mur- 
sounds  (quality,  pitch,  intensity,  and  duration)  are  also 
of  some  importance,  particularly  the  quality,  but  these 
are  secondary  to  other  considerations,  as  will  be  seen. 
The  loudness  or  feebleness  of  a  murmur  does  not  indi- 
cate the  amount  or  gravity  of  the  lesion  giving  rise  to 
it.  This  is  better  told  by  the  change  in  the  form  and 
size  of  the  heart  produced,  and  other  considerations  to 
be  noted.  The  fact  that  a  murmur  is  heard  about  the 
heart  is  no  sign  of  itself  that  the  heart  is  diseased  at 
all,  since  there  are  many  murmurs  that  are  independent 
of  actual  cardiac  disease,  however  closely  they  may  imi- 
tate true  organic  cardiac  murmurs.  It  is  the  business 
of  the  examiner  to  distinguish  between  them,  as  can 
usually  be  done  by  careful  and  intelligent  observation. 

There  are  other  considerations,  therefore,  far  more  im- 
portant than  the  mere  fact  of  the  presence  of  a  mur- 
mur in  connection  with  the  examination  of  the  heart. 


MITRAL   MURMURS.  197 

Individual  murmurs  usually  have  certain  points  of 
maximum  intensity,  as  well  as  areas  of  convection,  con- 
duction, or  transmission,  provided  they  are  of  the  aver- 
age intensity.  But  it  sometimes  happens  that  any 
murmur  may  be  so  loud  as  to  be  heard  all  over  the 
body,  whereas  that  which  is  usually  the  loudest  mur- 
mur may  be,  or  become,  so  feeble  as  to  be  heard  with 
difficulty,  if  at  all,  at  its  point  of  maximum  intensity. 
We  will  now  consider  the  murmurs  and  other  physical 
signs  characteristic  of  valvular  lesions,  in  the  regular 
order  of  their  occurrence. 

Murmurs  heard  loudest  at  the  Apex. — Mitral 
Murmurs. 

We  have  already  shown  that  there  are  four  points 
on  the  front  of  the  chest  wall  whera  the  various  heart- 
sounds  and  murmurs  may  be  heard  respectively  in  their 
maximum  intensity.  Mitral  murmurs,  for  instance,  are 
heard  loudest  at  the  apex,  tricuspid  murmurs  over  the 
ensiform  cartilage,  aortic  murmurs  usually  over  the 
aortic  interspace,  and  j^u^lnionary  murmurs  over  the 
pulmonary  interspace. 

Omitting  pericardial  and  pleuro-cardial  friction 
sounds,  to  be  presently  considered,  there  are  five  mur- 
murs heard  only,  or  loudest,  at  the  apex,  and  are  con- 
sequently referable  to  the  mitral  orifice  and  left  ventri- 
cle. Four  of  these  murmurs  are  systolic  in  time,  and 
one  prsesystolic.  The  four  systolic  murmurs  are  the 
mitral  regurgitant,  intra-ventricular,  dynamic,  and 
cardio-respiratory.  Of  these,  the  mitral  regurgitant 
and  intra-ventricular  murmurs  are  organic,  the  dynamic 
and  cardio-respiratory  being  inorganic,  or  functional. 


198  PHYSICAL    DIAGNOSIS. 

The  prsesystolic  murmur  is  also  organic,  being  due  to 
mitral  obstruction.  Of  these  five  mitral  apex  murmurs, 
therefore,  three  are  organic  and  two  are  inorganic,  or 
functional.     Comj)are  the  following  table: 


Mitral  or 

Apex 
Murmurs 


Mitral  Regurgitant 
Intra- Ventricular, 
r  systolic        i  n^„^i„  j  geu.,o.ie  origm. 


Cardio-respiratory. 
Praesj'stolic  .  .  Mitral  Obstructive. 

Mitral  Reguegitatiox. 

Mitral  regurgitation  (reflux,  insufficiency)  is  the  most 
frequent  of  all  valvular  lesions  of  the  heart.  It  is  usu- 
ally a  primary  result  of  endocarditis,  although  it  may 
be  relative  or  secondary  to  aortic  regurgitation,  or  even 
marked  aortic  obstruction,  which  might  lead  to  such 
dilated  hj-pertrophy  of  the  left  ventricle  that  the  mitral 
valves  would  become  insufficient.  Such  cases  are,  how- 
ever, compai-atively  rare,  and,  as  already  said,  it  is 
nearly  always  the  direct  result  of  endocarditis  affecting 
the  mitral  valves  themselves. 

Mitral  regurgitation  leads  to  the  following  change  in 
the  form  of  the  normal  heart:  (1)  enlargement  (dilated 
hypertrophy)  of  the  left  auricle ;  (2)  enlargement  of  the 
left  ventricle,  and  (3)  enlargement  of  the  right  ventricle. 

It  is  easy  to  understand  why  the  left  auricle  and 
right  ventiicle  become  enlarged.  The  blood  regurgi- 
tating back  into  the  left  auricle  during  ventricular  sys- 
tole, instead  of  going  on  through  the  aortic  orifice, 
gives  the  left  auricle  increased  work  to  do,  and  it  nec- 
essarily becomes  enlarged  (dilated  hj7)ertrophy).  In 
the  same  way,  the  blood  forced  back  on  the  lungs  gives 
the  right  ventricle  more  work  to  do  in  driving  blood 


MITRAL   REGURGITATION.  199 

through  the  hmgs.  But  just  why  the  left  ventricle  be- 
comes enlarged  also,  the  mechanism  is  not  so  clear. 
As  Walshe  says,  the  enlargement  of  the  left  ventricle 
in  these  cases  "  is  plainly  supplemental ;  though  it  is 
difficult  to  see  how  a  condition  that  makes  regurgita- 
tion more  forcible,  can  tend  to  ])alance  the  evils  arising 
from  it."  In  regard  to  this  point,  my  attention  was 
called  by  my  clinical  assistant,  Dr.  William  C  Rives, 
to  A'^ierordt,  of  Leipsic,  who,  says  truly,  that  "  the  left 
ventricle  first  becomes  dilated  from  having  blood  under 
abnormally  high  pressure,  and  increased  in  quantity, 
driven  into  it  during  its  diastole  by  the  enlarged  left 
auricle.  The  ventricle  then  becomes  hypertrophied  in 
order  to  dispose  of  this  extra  quantity  of  blood,  partly 
forward  into  the  aorta,  and  partly  backward  into  the 
left  auricle."  Tliat  seems  to  be  the  correct  view  of  the 
matter,  but  whatever  theories  there  may  be  about  it, 
one  thing  is  certain,  and  that  is  that  in  mitral  regurgi- 
tation the  left  ventricle  becomes  enlarged  in  some  way 
from  overwork. 

Another  iDoint  is  not  to  be  overlooked.  The  second 
sound  of  the  heart  is  louder,  usually,  than  normal  over 
both  the  pulmonary  and  aortic  interspaces  (second  in- 
terspaces on  the  left  and  right  side  of  the  sternum  re- 
spectively). But  as  heard  over  the  puhnonary  inter- 
sjpace  it  is  often  somewhat  louder  (accentuated)  than 
that  heard  over  the  aortic  interspace,  the  latter  being 
the  weaker  of  the  two,  owing  to  regurgitation  at  the 
mitral  orifice.  The  reason  for  this  accentuation  of  the 
second  sound  of  the  heart  over  the  pulmonary  inter- 
space is  obvious.     Owing  to  enlargement  (dilated  hy- 


200  PHYSICAL    DIAGNOSIS. 

pertrophy)  of  the  riglit  ventricle,  the  blood  is  thrown 
with  increased  force  into  the  pulmonary  artery,  and 
owing  to  increased  tension  in  that  vessel,  the  valves 
close  more  forcibly,  until  relative  tricuspid  insufficiency 
occurs.  This  phenomenon  is  still  more  marked  in  mi- 
tral obstruction,  as  we  shall  see. 

The  radial  pulse  will  be  found  also  in  mitral  regur- 
gitation to  be  irregular  in  size,  sometimes  large,  some- 
times small,  and  generally  compressible.  It  may  also 
intermit,  but  irregular  rhythm  is  not  peculiar  to  any 
valvular  lesion,  as  we  shall  see  when  speaking  of  ir- 
regular rhythm  in  general  (p.  264). 

Fig.  23.— Diagram  of  Sphygmographic  Tracing  of  Pulse  in  Mitral  Regurgitation. 

(Walshe.) 

In  the  early  existence  of  mitral  i-egurgitation,  before 
enlargement  has  had  time  to  occur,  as  in  other  lesions, 
or  toward  the  end,  when  there  are  dilation  and  feeble- 
ness of  action,  with  perhaps  pulmonary  infarctions  and 
other  comj)lications  that  are  likely  to  arise,  the  phys- 
ical signs  are  not  usually  so  clear.  But  in  general  they 
are  as  follows : 

Inspection. — The  apex-beat  is  usually  visible,  owing 
to  its  force  from  enlargement,  and  is  observed  to  be 
disi)laced  downward  and  outside  of  the  mammillary 
line,  indicating  enlargement  of  the  left  ventricle.  This 
is  of  the  utmost  importance  in  tlie  diagnosis  of  this 
disease.    The  heart's  impulse  is  usually  seen  to  be  more 


MITRAL  REGURGITATION.  201 

forcible  than  normal.  Sometimes,  in  persons  with  thin 
chest  walls,  left  auricular  impulse  is  observed  in  tlie 
pulmonary  (left  second)  interspace,  and  will  be  one  of 
two  kinds :  (1)  systolic,  if  communicated  to  the  auricle 
from  the  ventricle;  or  (2)  prsesystolic  (auriculo-sys- 
tolic),  if  due  to  hypertrophy  of  the  auricle.  As  the 
case  progresses,  jugular  pulsation  on  the  right  side 
of  the  neck  may  be  observed,  due  to  relative  tricus- 


FiG.  24.— Diagram  of  the  Heart  iu  Mitral  Regurgitation.      Left  Ventricle,  Left 
Auricle,  and  Right  Ventricle  are  seen  to  be  Enlarged— compare  normal  heart. 

pid  insufficiency  from  enlargement  of  the  right  ven- 
tricle. 

Palpation. — The  apex-beat  will  be  felt  downward 
and  outward  away  from  its  normal  x^osition,  and  the 
heart's  impulse  will  be  felt  to  be  generally  increased  in 
force.  Pulsation  near  the  ensiform  cartilage  is  some- 
times seen  and  felt,  and  is  due  to  enlargement  and 
forcible  action  of  the  right  ventricle.  The  latter  sign 
is  not  so  well  marked  here  as  in  general  emphysema, 
when  the  right  ventricle  alone  is  enlarged,  and  the 


202  PHYSICAL    DIAGNOSIS. 

wliole  heart  is  also  pushed  down  by  the  increased  vol- 
ume of  the  lungs. 

Purring  Thrill. — In  some  cases  of  mitral  regurgita- 
tion, a  systolic  j)urring  thrill  is  distinctlj^  felt,  especially 
if  the  palm  of  the  hand  is  placed  very  lightly  over  the 
lower  prsecordium.  It  is  usually  felt  in  the  fourth  in- 
terspace, on  or  near  the  mammillary  line.  Purring  thrill 
here,  as  in  other  cases  of  valvular  disease,  depends  for 
its  production  upon  three  abnormal  factors:  (1)  in- 
creased capacity  of  the  heart,  (2)  increased  propelling 
force,  and  (3)  an  abnormal  orifice.  It  will  not  be  pro- 
duced by  increased  force  and  an  abnormal  orifice  alone. 
Besides  hyx)ertrophy,  there  must  also  be  enlargement 
of  the  cavity  of  the  heart,  \^dth  a  certain  amount  of 
thinness  of  its  walls,  as  seen  after  dilatation  has  oc- 
curred to  some  extent.  With  increased  capacity  and 
force,  and  a  stream  of  blood  driven  through  a  button- 
hole orifice,  for  instance,  thrill  is  almost  certain  to  oc- 
cur. But  it  may  also  be  due  in  some  instances,  I  think, 
to  a  ribbon-like  vegetation,  with  one  end  free  and  vi- 
brating in  the  course  of  the  blood  current.  HoAvever 
this  may  be,  thrill  is  not  a  constant  phenomenon.  It 
will  disappear  from  changes  in  the  orifice,  or  after  hy- 
pertrophy ceases  to  compensate,  and  the  walls  of  the 
heart  become  weak.  The  disappearance  of  thrill,  there- 
fore, after  it  has  once  been  present,  would  seem  to  be 
not  always  a  favorable  sign. 

Percussion. — The  areas  of  both  deep  and  superficial . 
dullness  are  enlarged,  the  latter  especially,  downward 
and  to  the  left.     Dullness  over  the  left  auricle,  especi- 
ally among  those  with  thin  chest  walls,  is  more  marked 


MITRAL  KEGURGITATIOX.  20:} 

and  extends  beyond  the  normal  limits  already  men- 
tioned. 

AicsGultation. — A  blowing  systolic  murmur  is  heard, 
but  loudest  at  the  apex,  for  reasons  ah-eady  given  (p. 
189),  and  the  second  sound  of  the  heart  is  usually  more 
or  less  accentuated  over  the  pulmonary  (left  second) 
interspace,  since  the  enlarged  right  ventricle  would 
cause  greater  tension  in  the  pulmonary  artery,  with 
consequently  more  forcible  closure  of  the  pulmonary 
valves  than  would  be  the  case  in  the  aorta.  After  tri- 
cuspid insufficiency  occurs,  this  accentuation  is  not  so 
marked.  This  murmur  has  various  other  names,  such 
as  mitral  systolic,  mitral  indirect,  and  mitral  insuffi- 
cient. 

The  mitral  regurgitant  (systolic,  indirect,  insuffi- 
cient) murmur  is,  as  already  stated,  usually  blowing  in 
quality,  and  occurs  with,  or  takes  the  place  of,  the 
first  (systolic)  sound  of  the  heart.  It  also  occurs, 
therefore,  with  the  apex -beat.  By  paying  attention 
to  the  last  named  point,  the  time  of  the  murmur  can 
usually  be  fixed,  even  if  the  heart's  rhythm  be  irregu- 
lar. The  following  diagram  represents  the  mitral  re- 
gurgitant murmur : 

n-pli         dup 

Musical  Murmurs. — Sometimes  these  and  other 
murmurs  are  musical,  instead  of  possessing  a  blowing, 
blubbering,  rough,  or  other  quality.  This  quality  is  of 
no  particular  import,  but  simply  indicates  that  "  prom- 
inent spiculse  or  fibrinous  particles,  of  vibratile  charac- 
ter, project  into  the  current,  or  else  that  rigid  vibratile 
edges  bound  a  narrow,  chink-like  opening  "  (Walshe). 


204  PHYSICAL    DIAGNOSIS. 

Area  of  Transinisslon. — If  the  murmur  be  a  very 
feeble  one,  as  may  occur  in  cases  of  long  standing,  with 
marked  dilatation  of  the  heart  and  feebleness  of  its 
action,  especially  if  the  chest  walls  be  thick  and  fleshy, 
it  may  be  heard  only  at  the  apex,  and  then  with  diffi- 
culty. But  if  it  be  heard  anywhere  it  will  usually  be 
at  the  apex,  which  is  composed  of  the  left  ventricle, 
the  right  ventricle  being  in  front  of  the  body  of  the 
left.  But  if  the  mitral  regurgitant  murmur  be  a  very 
loud  one,  especially  if  it  be  musical,  as  sometimes  hap- 
pens with  any  murmur,  as  already  described,  then  it 
may  not  only  be  heard  at  the  apex,  but  all  over  the 
chest.  The  average  mitral  regurgitant  murmur  may, 
however,  besides  being  heard  loudest  at  the  apex,  be 
also  heard  over  three  other  localities:  (1)  posteriorly, 
between  the  inferior  angle  of  the  scapula  and  body  of 
the  eighth  dorsal  vertebra,  or  thereabouts;  (2)  along  the 
left  lateral  base  of  the  chest ;  and  (3)  over  the  left  auri- 
cle and  to  the  left  of  it.  In  the  first  case,  we  are  listen- 
ing directly  over  the  site  of  the  mitral  valves,  and  this 
is  perhaps  the  only  case  in  which  we  listen  directly 
over  the  site  of  the  valves  of  the  heart  for  sounds  in 
connection  with  them.  Though  usually  heard  behind 
at  that  point,  it  is  not  necessarily  heard  there.  The 
murmur  may  be  too  weak,  as  already  stated;  or  the 
patient  may  have  an  emphysematous  lung  interj^osed; 
or,  as  in  the  case  of  a  lady  from  Canada,  whom  I  exam- 
ined, the  murmur  was  distinctly  heard  behind,  until 
accidentally  falling  ill  with  pleurisy  with  effusion,  the 
murmur  disappeared  posteriorly,  and  though  she  made 
a  fair  recovery  from  the  j^leurisy,  the  murmur  never 
again   returned   to   that   point.      Enlarged   bronchial 


MITRAL  REGURGITATlOlSr,  2()o 

glands    aud    other   acoustic    impediments    evidently 
might  prevent  such  a  murmur  from  being  heard  behind. 

(2)  Besides  hearing  the  mitral  regurgitant  murmur 
at  the  heart's  apex,  and  posteriorly  over  the  mitral 
valves,  it  is  sometimes,  not  always,  transmitted  from 
the  apex  along  the  ribs  to  the  left;  but  it  is  not  so 
transmitted  to  the  point  behind  that  has  been  men- 
tioned. Why  is  it  that  this  murmur  is  sometimes 
heard  transmitted  along  the  ribs  to  the  left,  and  some- 
times not?  There  are  two  classes  of  causes.  First  and 
chiefly,  if  the  right  ventricle  becomes  very  much  en- 
larged, it  acts  as  a  wedge  between  the  left  ventricle  and 
the  chest  wall,  and  pushes  the  left  ventricle  back  so  far 
that  it  is  impossible  for  the  ribs  to  take  up  the  sound. 
In  these  cases  it  will  be  very  distinct  posteriorly,  not  so 
much  as  is  usual  at  the  apex,  and  not  heard  at  all  to 
the  left.  Such  conditions  would  indicate  a  very  large 
right  ventricle.  The  second  class  of  causes  would  be 
pleurisy  with  effusion,  thickened  pleura,  emphysema, 
or  some  other  acoustic  impediment. 

(3)  Lastly,  if  the  left  auricle  be  greatly  enlarged  and 
the  murmur  be  communicated  to  it,  the  murmur  may 
be  heard  in  the  third  and  even  second,  interspace  on 
the  left  of  the  sternum,  over  the  site  of  the  left  auricle, 
and  thence  transmitted  to  the  left  axilla. 

Diagnosis  of  Mitral  Regurgitation. — If  the  exist- 
ence of  mitral  regurgitant  murmur  can  be  established, 
the  diagnosis  is  complete.  But  the  extent  of  the  lesion 
here,  as  elsewhere,  cannot  be  accurately  estimated  by 
the  properties  of  the  murmur,  but  by  the  amount  of 
cardiac  enlargement  produced. 

Pericardial  (exo-cardial)  friction  sounds  are  super- 


206  PilYSICAL    DIAGNOSIS. 

ficial,  rubbing,  churning,  grazing  or  creaking  in  quality, 
are  not  transmitted  beyond  the  limits  of  the  heart, 
change  in  intensity  with  position  of  the  patient  in 
leaning  forward  or  backward,  or  by  pressure  with  the 
stethoscope,  and  have  no  fixed  relation  in  time  to  the 
heart-sounds. 

Pleuro-cardial,  or  pleuritic  friction  sounds,  near  by, 
may  be  kept  up  by  the  heart's  impulse,  and  do  not 
necessarily  cease  upon  holding  the  breath,  but  are  easily 
distinguished  by  their  quality  and  the  circumscribed 
area  to  which  they  are  limited.  There  remain  three 
other  systolic  apex  murmurs,  which  may  very  closely 
imitate  the  mitral  regurgitant,  and  it  is  necessary  to 
know  how  to  distinguish  them.  They  are  (1)  intra- 
ventricular murmurs,  termed  also  by  Flint  and  others 
the  mitral  systolic  non-reguigitant  murmur,  (2)  dy- 
namic, and  (3)  cardio-respiratory  murmurs.  Intra-ven- 
tricular  murmurs  are  organic,  whereas  the  dynamic 
and  cardio-respiratory  murmurs  are  inorganic,  or  func- 
tional. 

(1)  Intra-ventricular  murmurs,  when  they  exist, 
are  usually  so  feeble  that  they  may  be  heard  at  the 
apex  only,  or  base.  In  either  case  they  are  always 
systolic,  and  due  to  lesions  somewhere  within  the  ven- 
tricle, instead  of  affecting  the  orifices  or  valves.  Some 
of  the  intra-ventricular  murmurs  are  heard  only  at  the 
apex,  others  at  the  base,  others  again  more  or  less  over 
the  whole  heart.  They  are  due  to  loughening  of  the 
ventriculai'  endocardium,  misattachnient  of  a  chord, 
fibrinous  shreds  across  the  blood  current,  thickening 
and  roughening  of  cliords,  twisting  of  columnar  carne^e, 
inflammatory  vegetations  on  the  wall  of  the  ventricle, 


MITKAL   REGURGITATION.  207 

and  cardiac  ventricular  aneurism.  In  the  latter  case 
the  ventricle  is  enlarged,  and  it  may  be  impossible  to 
make  a  diagnosis ;  but  in  all  other  cases  of  intra- ven- 
tricular murmurs  the  diagnosis  is  easy,  since  the  cause 
of  their  production  is  not  a  cause  for  enlargement  or 
perceptible  interference  with  the  circulation.  The  mur- 
murs of  this  variety  are  usually  weak,  and  for  that 
reason  only  are  restricted  to  a  spot  over  the  apex,  and 
are  not  transmitted  anywhere,  or  heard  posteriorly. 
The  x^rognosis  in  the  two  cases  would  be  entirely  differ- 
ent. For  whereas  mitral  regurgitation  is  usually  fatal 
in  course  of  time,  owing  to  pulmonary  congestion,  sec- 
ondary tricusx>id  insufficiency,  hemorrhagic  infarctions 
of  the  lungs,  and  cardiac  droi)sy,  intra-ventricular 
lesions  may  be  of  little  or  no  imi3ortance,  though  suffi- 
cient to  produce  a  murmur. 

(2)  Dynamic  Murmurs. — These  murmurs  are  due 
to  some  perverted  action  of  the  heart,  and  are  observed 
sometimes  in  choreic  subjects.  The  heart  is  a  volun- 
tary muscle,  and  hence  subject  to  choreic,  irregular 
movements,  like  other  voluntary  muscles.  Conse- 
quently, during  systole,  some  of  the  column^e  carneae 
twitch  and  x)ull  the  mitral  valves  open,  causing  a  faint 
murmur,  which  is  only  audible  at  the  apex.  Not  only 
so,  but  it  is  not  necessarily  associated  with  left  ven- 
tricular, or  other  cardiac  enlargement,  and,  moreover, 
the  dynamic  murmur  from  this  cause  is  very  incon- 
stant, dependent,  as  it  is,  upon  choreic  movements 
which  are  absolutely  uncertain.  It  is  sometimes  found, 
also,  in  those  who  are  nervous  from  other  causes,  as 
among  hysterical  women,  tobacco  smokers,  and  rarely 
among  those  nervous  from  abuse  of  alcohol.     It  is  also 


208  PHYSICAL    DIAGNOSIS. 

heard  sometimes  in  epilei)tic  subjects.  But  in  all  such 
cases  the  murmur  is  weak,  and  hence  limited  to  the 
apex  usually,  is  not  necessarily  attended  with  enlarge- 
ment of  the  heart,  and,  above  all,  is  inconstant. 

Dynamic  murmurs,  instead  of  being  of  neurotic  ori- 
gin, may  also  be  due  to  anaemia.  ISTo  truly  hsemic 
murmur  is  ever  heard  at  the  apex,  unless  produced  by 
heart  clot,  which  is  very  rare.  But  hsemic  munnurs 
due  to  the  watery  condition  of  the  blood  are  heard  only 
at  the  base  and  over  the  pulmonary  interspace,  unless 
caught  up  by  the  aorta,  and  are  caused  by  watery 
venous  blood,  as  will  be  considered  fully  when  speak- 
ing of  basic  murmurs.  That  anaemia  does  give  rise 
indirectly,  or  dynamically,  to  a  systolic  apex  murmur, 
besides  causing  all  cardiac  murmurs  to  be  louder  than 
they  would  be  otherwise,  by  increasing  vibratility  of 
tissues,  cannot  be  denied.  But  such  a  systolic  apex 
murmur  should  not,  strictly  speaking,  be  termed  an 
anaemic  murmur,  but  a  dynamic  murmur  due  to  anae- 
mia. Tlie  mode  of  its  production  is  as  follows:  The 
heart  becomes  flabby,  and  the  papillary  muscles  become 
weak  from  fatty  degeneration,  according  to  Guttmann 
and  others,  thus  allowing  the  mitral  valves  to  recoil 
too  far,  so  as  to  cause  a  slight  backward  leakage;  or 
else  temporary  dilatation  from  auccmia  may  allow  a 
vortiginous  (eddying)  movement  of  the  blood  within 
the  ventricle,  or  misdirection  of  its  current,  sufficient 
to  give  rise  to  a  systolic  munnur. 

The  masturbator's  systolic  apex  murmur,  described 
by  Walshe,  and  attributed  by  him  to  nervous  in- 
fluence, may  also  be  due  to  the  anaemic  condition  of  the 
patient. 


MITRAL    OHSTllUCTIOiV.  209 

By  curing  such  patients  of  their  anaemia  by  means 
of  iron  and  nutritious  diet,  these  murmurs  will  disap- 
X)ear,  it  is  true,  but  even  then  they  are  not  to  be  regarded 
as  true  hsemic  murmurs,  though  venous  hum  be  also 
l)resent,  but  as  dynamic  murmurs  due  to  the  anaemic 
condition.  The  venous  hum  in  the  neck,  with  which 
they  are  usually  associated,  will  be  fully  considered  in 
connection  with  basic  heart  murmurs. 

(3)  Cardio-respiratory  murmicrs  are  always  sys- 
tolic, and  heard  at  the  end  of  a  full  insj^iration,  as  the 
heart's  impulse  may  force  air  out  of  some  vesicles  or 
cavities  near  by,  with  a  sound  that  sometimes  imitates 
the  cardiac  systolic  murmur;  or  the  respiratory  mur- 
mur itself  may  sound  like  a  heart  murmur  during  sys- 
tole. Simply  have  the  i)atient  hold  the  breath  after 
€X]piration,  and  the  imitation  heart  murmur  at  once 
ceases.  It  is  always  a  good  rule,  during  auscultation 
of  the  heart,  to  have  the  patient  hold  the  breath  at 
least  once  for  each  point  examined. 

MiTEAL   ObSTRUCTIOjVT. 

Mitral  obstruction  (constriction,  stenosis)  is  said  by 
some  authors  to  be  idiox)athic,  or  congenital,  and  not 
traceable  to  j)revious  rheumatic  endocarditis,  or  other 
disease.  In  these  cases  it  chiefly  affects  women  and 
children.  But  it  not  infrequently  does  result  from 
rheumatic  endocarditis  in  the  young  of  both  sexes. 
Aortic,  rather  than  mitral  lesions,  are  apt  to  occur  after 
middle  life. 

Mitral  obstruction  leads  to  enlargement  (1)  of  the 

left  auricle,  and  (2)  of  the  right  ventricle,  and  by  en- 
14 


210  PJIVSICAL    DIAG.NOSIS. 

largement  is  meant  here,  as  elsewhere,  dilated  hyper- 
trophy. 

The  difference  in  enlargement,  therefore,  in  mitral 
obstruction  and  regurgitation,  is  the  left  ventricle.  In 
obstruction  it  is  not  only  not  enlarged,  but,  on  the  con- 
ti'ary,  somewhat  smaller  than  normal,  from  diminished 
volume  of  blood  entering  it ;  but  in  mitral  regurgita- 
tion it  is  enlarged,  as  already  mentioned.  In  mitral 
obstruction  the  left  auricle  becomes  enlarged,  from  the 


Fig.  25.— Enlargement  of  the  Left  Auricle  and  KiKlit  Ventricle  iu  Mitral  Obstruction. 

effort  to  drive  blood  through  an  o])structed  orifice,  and 
the  blood,  being  prevented  from  leaving  the  lungs 
freely,  the  i-ight  ventricle  becomes  enlarged  from  the 
extra  task  of  driving  the  blood  through  them.  The 
fact  that  the  left  ventricle  is  not  enlarged  in  mitral  ob- 
struction is  of  the  greatest  imj)ortance  in  making  a 
correct  diagnosis.  The  second  sound  of  the  heart  is 
usually  accentuated  in  the  i)Tdmonary  intersi)ace,  for 
I'easons  already  given  (p.  199),  and  weakened  in  the 
aortic  interspace,  for  the  reason  that  the  left  ventricle 


MITKAL   OBSTRUCTION.  211 

is  somewhat  atrophied,  with  consequent  diminished 
tension  in  the  aorta.  The  difference  is  more  marked 
here  than  in  mitral  regurgitjition. 

In  addition  to  this  accentuation,  the  second  sound  is 
also  reduplicated  at  the  base  in  about  one  third  of  all 
cases,  as  the  ^Dulmonary  valves  close  not  only  more 
forcibly  than  the  aortic,  due  to  increased  tension  in 
the  pulmonary  artery,  from  enlargement  of  the  right 
ventricle,  but  also  earlier  than  the  aortic  valves,  for  the 
same  reason. 

The  radial  pulse  is  not  noticeably  aifected  in  mitral 
obstruction,  nor  is  the  heart's  rhythm  necessarily  dis- 
turbed, but  is  generally  regular.  The  physical  signs 
of  mitral  obstruction  are : 

Inspection. — The  apex-beat,  if  seen  at  all,  will  usu- 
ally be  within  the  mammillary  line,  as  the  left  ventricle 
is  not  enlarged.  It  may  be  pushed  out  a  little,  how- 
ever, by  enlargement  of  the  right  ventricle.  The  apex- 
beat  will  be  observed  to  be  not  more  forcible,  i^erhaps, 
than  in  health.  But  there  may  be  observed  in  those 
having  thin  chest  walls  a  left  auricular  systolic  im- 
pulse over  the  left  third  interspace,  owing  to  enlarge- 
ment of  the  left  auricle.  This  impulse  immediately 
precedes  the  a^Dex-beat,  and  with  regard  to  the  latter  is 
prgesystolic.  Pulsation  of  the  enlarged  right  ventricle 
will  not  be  observed  usually,  unless  the  heart  be  lowered 
from  some  cause,  when  it  will  be  observed  near  the  end 
of  the  ensiform  cartilage,  as  in  general  vesicular  em- 
physema. 

Mitral  obstruction  occurring  in  children  appears  to  be 
not  infrequently  associated  with  the  so-called  pigeon- 
breast.     The   flattening  is   especially   well-marked   in 


212  PHYSICAL    DIAGXOSIS. 

the  lower  prsecordial  region  on  tlie  left  of  the  sternum. 
^ATiether  this  is  mere  coincidence  in  a  certain  number 
of  cases,  or  due  to  atrophy  of  the  left  ventricle,  or  to 
lack  of  nutrition  in  general,  from  imperfect  cardiac 
function,  is  not  exactly  known. 

As  the  case  progresses  and  relative  insufficiency  of 
the  tricuspid  valves  occurs,  due  to  excessive  dilated 
hypertrophy  of  the  right  ventricle,  jugular  pulsation 
on  the  right  side  of  the  neck,  and  afterward  also  on 
the  left  side,  will  be  observed.  Then  follows  cardiac 
dropsy,  commencing  in  the  feet. 

.Palpation. — The  ai^ex-beat  may  be  felt  to  be  not 
markedly  displaced  or  increased,  and  there  may  be 
some  pulsation  near  the  end  of  the  ensiform  cartilage, 
due  to  enlargement  of  the  right  ventricle,  if  the  heart 
be  sufficiently  lowered.  But  what  is  most  distinctive 
is  the  presystolic  thrill  often  felt  about  the  left  fourth 
interspace.  By  i^lacing  the  palm  of  the  hand  lightly 
over  the  part,  the  thrill  may  be  felt  immediately  before 
the  apex-beat,  and  it  is  characteristic  of  mitral  ob- 
struction, though  not  always  present.  It  is  due  to  the 
forcible  contraction  of  the  enlarged  left  auricle  in  its 
endeavor  to  force  the  blood  through  an  obstructed  ori- 
fice. The  general  mode  of  production  is  the  same  here 
as  in  regurgitation  (which  see,  p.  202)  and  elsewhere, 
and,  like  that,  is  not  permanent.  Auricular  impulse, 
pr^esystolic  in  time  with  regard  to  tlie  apex-beat,  is 
sometimes  felt. 

Percussion. — The  area  of  dullness  over  the  left  auri- 
cle and  right  ventricle  is  enlarged,  but  what  is  known 
as  the  superficial  area  of  cardiac  dullness  is  not  so 
much  enlarged  as  in  mitral  regurgitation,  since  in  mi- 


MITEAL   OBSTRUCTION.  213 

tral  obstruction  the  left  ventricle  is  not  enlarged,  and 
a  small  part  of  the  superficial  area  of  dullness  is  nor- 
mally formed  of  the  left  ventricle. 

Auscultation. — A  blubbering  j)r^systolic  murmur, 
like  vibrating  the  letter  r  with  the  tongue,  or  vibra- 
ting the  flaccid  lips  by  blowing  forcibly  (expiration) 
through  them  while  they  are  closed  (Flint),  is  usually 
heard  loudest  at  the  apex,  and  limited  to  that  region, 
though  it  may  be  conveyed  up  to  the  fourth  interspace 
by  the  blood  current,  and  in  some  rare  cases  is  so  loud 
as  to  be  heard  behind — in  fact,  all  over  the  chest.  The 
second  sound  of  the  heart  is  usually  accentuated  over 
the  pulmonary  interspace.  The  murmur  has  various 
names,  such  as  prsesystolic,  direct,  constrictive,  stenotic, 
and  so  on.  As  the  murmur  in  regurgitation  is  termed 
regurgitant,  so  in  obstruction  it  may  be  called  obstruct- 
ant  or  obstructive. 

The  mitral  obstructive  (direct,  stenotic,  constrictive, 
prsesystolic)  murmur  is  usually  blubbering  in  quality, 
as  akeady  stated,  and  unless  it  is  blubbering  it  is  usu- 
ally absent  altogether,  for  this  is  the  only  organic  heart 
murmur  that  may  appear  and  disappear.  All  other 
organic  heart  murmurs  are  permanent.  The  reason 
why  it  is  blubbering,  as  Flint  explains,  is  because  of 
the  vibration  of  the  free  edges  of  the  valves,  the  orifice 
between  them  being  narrow  and  bottonhole-like.  It  is 
like  throwing  the  flaccid  lips  into  vibration,  by  forcibly 
expelling  the  breath  while  the  mouth  is  gently  closed, 
which,  as  Flint  truly  states,  "  represents  not  only  the 
characteristic  quality  of  the  murmur,  but  the  mode  of 
its  production."  AVhen  the  edges  of  the  mitral  valves, 
instead  of  being  flaccid,  become  fixed  from  inflamma- 


214  PHYSICAL    DIAGNOSIS. 

tion,  the  murmnr  ceases  and  regurgitation  follows.  It 
also  ceases  if  the  circulation  is  feeble,  but  in  that  case 
it  may  return  with  thrill  on  exercising.  The  follow- 
ing diagram  represents  the  mitral  obstructive  mur- 
mur : 

r-r-nh         dup 
I 1    I 1 I 

This  blubbering  murmur  at  the  apex,  according  to 
Flint,  is  sometimes  due  to  aortic  regurgitation,  causing 
a  secondary,  or  relative,  mitral  obstruction.  In  this 
case  the  edges  of  the  healthy  mitral  valves  are  thrown 
into  vibration  slightly  by  the  blood  from  the  left  auri- 
cle, while  they  are  being  closed  by  the  backward  press- 
ure of  blood  due  to  aortic  regurgitation.  This  is  differ- 
ent from  the  aortic  diastolic  regurgitant  murmur  that 
is  sometimes  transmitted  faintly  to  the  apex. 

The  mitral  obstructive  murmur  is  never  due  to  anae- 
mia, or  any  other  functional  or  inorganic  cause.  It  is 
always  an  organic  murmur,  due  usually  to  mitral  ob- 
struction primarily,  and  rarely  to  aortic  regurgitation, 
which  causes  a  secondary,  or  relative  mitral  obstruction. 
The  idea  that  there  is  no  such  thing,  in  fact,  as  a  mitral 
obstructive  (presystolic,  direct,  stenotic,  constrictive) 
murmur,  but  that  it  is  really  regurgitant,  originated,  it 
api:)ears,  with  Barclay.  Dickinson  and  others  have 
followed  Barclay  in  this  notion,  but  Gairdner,  Balfour, 
Bristowe,  Flint,  Loomis,  and  many  others  have  demon- 
strated quite  clearly  that  Barclay  and  his  followers 
were  mistaken.  For  according  to  Bristowe,  for  in- 
stance, if  the  mitral  ()l)structive  (prfesystolic,  direct, 
stenotic,  constrictive)  murmur  is  really  regurgitant, 
due  to  prolonged  contraction  of  the  ventricle,  then  in 


MITRAL   OBSTKUCTIOX.  215 

aortic  obstruction  there  ought  also  to  be  a  ju'sesystolic 
aortic  obstructive  murmur,  a  clear  case  of  reductio  ad 
ahsurdum.  Moreover,  jyost-mortem  examination  sets 
the  whole  matter  at  rest  in  favor  of  the  mitral  prse- 
systolic  (obstructive)  murmur. 

This  murmur  was  pointed  out,  in  1841,  by  Gendrin, 
of  Paris,  who  called  it  prsesystolic.  It  was  first  claimed 
to  be  due  to  mitral  obstruction  by  Fauvel,  of  Paris,  in 
1843.  In  1861,  Gairdner,  of  Glasgow,  named  it  left 
auriculo  systolic  murmur.  It  is  also  sometimes  called 
post-diastolic.  Guttmann  calls  it  a  diastolic  murmur. 
Flint,  however,  makes  the  mitral  diastolic  murmur  to 
be  different  from  the  mitral  praesystolic  murmur  proper, 
and  says  that  it  is  caused  by  the  rush  of  blood  through 
and  over  abnormal  structures  before  the  auricle  con- 
tracts. It  is  simply  a  part  of  the  same  murmur,  and 
may  be  said  to  be  a  distinction  without  a  difference. 
It  is  simi)ly  the  first  part  of  a  i)rolonged  mitral  ob- 
structive murmur,  which  occupies  the  whole  of  diastole 
instead  of  being  merely  prjesystolic. 

Area  of  Transmission. — The  mitral  obstructive 
murmur  is  usually  limited  to  the  region  of  the  apex, 
or  conveyed  u^^  the  ventricle  to  the  fourth  interspace, 
unless  it  is  very  loud,  when,  in  some  cases,  it  may  also 
be  heard  iDOsteriorly.  Why  is  not  this  murmur  usu- 
ally heard  posteriorly  at  a  point  between  the  inferior 
angle  of  the  scapula  and  body  of  the  seventh  or  eighth 
dorsal  vertebra,  as  in  the  case  of  mitral  regurgitation? 
Simply  ])ecause  the  murmur,  being  made  in  the  direc- 
tion of  the  blood  current,  and  not  against  it,  is  not  held 
at  the  mitral  orifice  long  enough  to  be  heard,  but  is  at 
once  carried  down  to  the  aj^ex,  where  it  is  heard.     On 


216  PHYSICAL    DIAGNOSIS. 

the  other  hand,  the  mitral  regurgitant  murmur  is  con- 
veyed backward  toward  the  ear,  when  auscultating 
posteriorly,  and  it  is  held  there  long  enough  to  l^e 
heard.  Why  is  not  the  mitral  obstructive  (prsesystolic, 
direct,  stenotic,  constrictive)  murmur  transmitted  along 
the  chest  walls  to  the  left,  as  in  the  case  of  mitral  re- 
gurgitant murmur?  Simply  because  in  mitral  obstruc- 
tion, the  left  ventricle  is  not  enlarged  and  the  right 
ventricle,  which  does  become  enlarged,  and  is  in  front 
of  the  left,  wedges  off  the  latter  from  the  chest  walls, 
so  that  it  does  not  come  near  enough  for  them  to  pick 
up  the  sound  of  the  murmur.  The  murmur  also  is 
prsesystolic,  and  occurs  before  the  apex  could  reach  the 
chest  walls,  even  if  the  enlarged  right  ventricle  were 
not  between  the  apex  and  the  chest  walls. 

Diagnosis. — Mitral  obstructive  murmur  would  not 
be  mistaken  for  mitral  regurgitant,  but  that  sometimes 
the  cardiac  rhythm  is  so  irregular,  and  the  sounds  may 
so  nearly  resemble  each  other,  that  it  is  difficult  to  tell 
the  first  sound  from  the  second.  In  these  cases,  as  well 
as  where  the  rhythm  is  perfectly  regular,  the  changes 
effected  in  the  form  and  size  of  the  heart  are  not  to  be 
overlooked.  For  besides  the  fact  that  mitral  obstruct- 
ive murmur  is  pra^systolic  in  time,  limited  to  the 
apex,  and  blubbering  in  quality,  while  mitral  regur- 
gitant is  systolic  in  time,  usually  heard  behind,  as  well 
as  at  the  apex,  sometimes  transmitted  along  the  left 
lateral  base  of  the  chest,  and  blowing  in  quality,  it, 
must  not  be  forgotten  that  in  mitral  obstruction  the 
left  ventricle  is  not  enlarged,  Avhile  in  mitral  regurgi- 
tation it  is  enlarged,  with  corresponding  displacement 
of  the  apex-beat  downward  and  outward,  usually  out- 


MITRAL  REGURGITATION  AND  OBSTRUCTION.       217 

side  of  the  mammillary  line.  Aortic  regurgitant 
sounds,  though  sometimes  conveyed  to  the  apex,  are 
attended  with  enlarged  left  ventricle,  besides  being 
purely  diastolic  in  time,  and  are  not  heard  loudest  at 
the  apex. 

A  rather  faint  mitral  presystolic  murmur  may  some- 
times be  heard,  due  to  relative  or  secondary  obstruc- 
tion to  the  onward  flow  of  blood  in  some  rare  cases  of 
aortic  regurgitation.  The  mitral  murmur  in  such  cases 
is  not  usually  attended  with  api^reciable  enlargement 
of  the  right  ventricle,  and  accentuation  of  the  second 
sound  in  the  pulmonary  interspace,  but  there  is  great 
enlargement  of  the  left  ventricle  which  does  not  occur 
in  mitral  obstruction. 

Mitral  Regurgitation  and  Obstruction. 

This  combination  of  lesions  not  infrequently  exists, 
for  it  is  perfectly  clear  that  while  the  mitral  ori- 
fice is  constricted  the  valves  may  be  prevented  from 
closure  by  adhesion.  In  such  a  case  there  would  be 
both  regurgitation  and  obstruction  at  the  same  orifice. 
Usually,  there  is  but  one  murmur  in  these  cases,  the 
mitral  regurgitant,  since,  as  already  remarked,  the  mi- 
tral obstructive  murmur  usually  ceases  when  the  free 
edges  of  the  valves  become  fixed  and  cannot  vibrate. 
Sometimes,  however,  both  murmurs  are  heard,  the  prfe- 
systolic  and  systolic — the  former  at  the  apex  and  trans- 
mitted upward  with  the  blood  current  toward  the 
fourth  intersx:)ace,  the  latter  also  at  the  apex,  but  trans- 
mitted around  toward  the  left,  and  sometimes  heard 
posteriorly.      The  left  ventricle,  the  left   auricle,  and 


218  niYSICAL    DIAGNOSIS. 

right  ventricle  are  enlai-gecl,  and  the  second  sound  is 
more  or  less  accentuated  in  the  j)ulmonary  interspace. 

Tricuspid  Regurgitation. 

Tricusj^id  murmurs  are  usually  so  feeble  that  they 
are  aiidible,  as  a  rule,  only  over  the  ensiform  cartilage. 
And  inasmuch  as  the  tricuspid  obstruction  (praisys- 
tolic,  direct,  stenotic,  constrictive)  murmur  is  so  rare 
that  it  may  practically  be  thrown  out  altogether,  there 
remains  only  the  tricuspid  regurgitant  murmur  to  be 
sought  for  in  connection  with  suspected  tricuspid 
lesions. 

Tricuspid  regurgitation  (reflux,  insufficiency)  is 
commonly  secondary  or  relative  to  enlargement  (di- 
lated hypertroi)liy)  of  the  right  ventricle,  due  to  mitral 
regurgitation  or  obstruction,  or  to  general  vesicular 
emphysema.  In  all  of  these  cases,  as  we  have  seen, 
the  right  ventricle  in  time  becomes  enlarged  from  the 
extra  work  i)ut  upon  it  in  order  to  drive  forwai'd  an 
impeded  pulmonary  circulation.  After  a  while,  in 
some  of  these  cases,  not  all,  the  tricuspid  valves  become 
so  wideh^  separated  that  tricuspid  regui'gitation  with 
jugular  pulsation  and  cardiac  dropsy  result. 

Primary  or  actual  tricuspid  regurgitation  sometimes 
is  met  \vith,  and  then  it  is  the  result  of  foetal  endo- 
carditis, as  has  already  been  referred  to.  It  leads  to 
enlargement  of  the  right  ventricle.  The  tricuspid  re- 
gurgitant murmur  is  systolic  in  time  and  blowing  in 
quality,  but  is  usually  so  feeble  that,  as  has  already 
been  stated,  it  is  confined  to  a  small  area  over  the  ensi- 
form cartilage.  Sometimes  the  aortic  regurgitant  mur- 
mur is  so  transmitted   down  the  sternum   that  it  is 


TRICUSPID   REGURGITATIOISr.  210 

heard  only  over  the  ensiforni  cartilage,  but  tricusjiid 
regurgitant  murmur  is  systolic,  while  aortic  regurgitant 
is  diastolic  in  time.  The  latter  is  also  accompanied  by 
enlargement  of  the  left  ventricle  and  other  signs  to  be 
described.  The  mitral  regurgitant  murmur  is  systolic 
in  time,  but  it  is  heard  loudest  at  the  apex  and  trans- 
mitted to  the  left,  besides  being  usually  heard  pos- 
teriorly. It  sometimes  exists  with  tricuspid  regurgita- 
tion, so  that  the  two  murmurs  run  into  each  other.  In 
this  case  the  other  signs  of  tricuspid  regurgitation  are 
to  be  considered,  such  as  jugular  jDulsation,  cyanosis, 
cardiac  dropsy  and  pulmonary  oedema.  The  character 
of  the  radial  pulse  is  not  affected  by  valvular  disturb- 
ances of  the  right  side  of  the  heart.  The  rhythm  is, 
however,  sometimes  irregular,  especially  in  general 
vesicular  emphysema  (p.  266).  There  are  no  intra- ven- 
tricular, dynamic,  or  cardio-respiratory  murmurs  to  be 
considered  usually  in  differentiating  the  tricuspid  re- 
gurgitant murmur.  Should  any  such  case  arise,  the 
same  rules  hold  good  in  regard  to  them,  and  peri- 
cardial, or  pleuro-cardial,  friction  sounds,  as  in  mitral 
regurgitation,  to  which  the  reader  is  referred. 

Jugular  Pulsation. — This  phenomenon  was  first 
observed  by  Lancisi,  of  Rome,  in  1728.  It  is  usually 
systolic,  but  is  sometimes  also  pr?esystolic. 

Systolic  jugular  pulsation  is  accounted  for  as  follows: 
In  tricuspid  insufficiency  from  any  cause,  venous  blood 
is  forced  back  during  systole  through  the  tricuspid 
orifice  into  the  right  auricle,  and  against  the  column  of 
blood  in  the  ven;e  cavse.  The  superior  vena  cava,  right 
vena  innominata,  and  right  internal  jugular  vein,  form 
a  sort  of  consolidated,  straight,  trunk  line,  so  to  speak, 


220  PHYSICAL    DIAGNOSIS. 

and  there  is  no  valve  in  the  way  until  we  come  to  the 
lower  end  of  the  internal  jugular  vein,  just  at  the  root 
of  the  neck.  Consequently,  this  systolic  i)ulsation  of 
venous  blood  always  first  occurs  on  the  right  side  at 
the  root  of  the  neck.  After  that  valve  gives  way,  the 
pulsation  extends  up  to  the  second  valve,  and  finally 


Fig.  26.— Jugular  Pulsation.    Position  and  Relation  of  the  Veins  of  the  Neck. 

may  reach  the  angle  of  the  jaw.  Meantime,  it  begins 
to  apj)ear  also  on  the  left  side,  but  not  so  forcibly,  as 
the  backward  shock  has  to  go  round  a  curve.  In  time, 
all  the  veins  about  the  neck  may  participate  in  this 
curious  phenomenon.  Slight  systolic  jugular  pulsation 
may,  according  to  Bamberger,  sometimes  be  observed 
on  the  right  side,  at  the  root  of  the  neck,  even  when 
the  tricusxjid  valves  are  not  actually  insufficient.  In 
right  ventricular  enlargement  a  slight  backward  shock 


AORTIC    MURMUKS.  221 

may  even  be  imparted  through  the  tricuspid  valves 
themselves. 

Pr?esystolic  jugular  pulsation  is  sometimes  seen  in 
cases  of  right  auricular  overflow,  during  contraction  of 
the  right  auricle,  and  just  before  systole  of  the  right 
ventricle,  but  it  is  rare.  It  sometimes  occurs  in  tricus- 
pid insufiiciency,  but  tricuspid  obstruction  would  also 
favor  its  production. 

Tricuspid  Obstructiois". 

This  lesion  is  very  rare,  and  even  when  it  is  present 
there  is  usually  no  murmur  heard  with  it.  This  is 
probably  owing  to  the  feebleness  of  the  venous  blood 
current  as  compared  with  the  arterial,  and  the  weak- 
ness of  the  right  auricle  as  compared  with  the  left. 
Usually,  it  is  only  on  post-mortem  examination  that 
tricuspid  obstruction  is  found  to  have  existed. 

Should  there  be  any  murmur  present  it  would  be 
presystolic,  as  in  the  case  of  mitral  obstruction,  but 
the  murmur  would  be  limited  to  the  region  of  the  en- 
siform  cartilage.  The  right  auricle  would  be  likely  to 
become  enlarged,  but  no  particular  change  in  the  form 
and  size  of  the  heart  is  known.  The  radial  pulse  would 
be  unaffected. 

Murmurs  heard  loudest  at  the  base.    Aortic 
Murmurs. 

We  have  seen  that  we  listen  over  the  apex  and  ensi- 
form  cartilage,  respectively,  in  order  to  hear  mitral  and 
tricuspid  murmurs  in  their  maximum  intensity.     We 


222 


PHYSICAL   DIAGNOSIS. 


now  come  to  a  third  point  on  tlie  front  of  the  chest 
walls,  \\-hich  is  the  aortic  interspace,  or  the  right  second 
intersi)ace,  being  that  between  the  second  and  third 
costal  cartilages,  on  the  right  of  the  sternum.  Here  we 
listen  for  murmurs  referable  to  the  aortic  orifice  in 
their  maximum  intensity  (pp.  187,  188). 

Omitting  pericardial  and  pleuro-cardial  friction 
sounds,  already  described  under  mitral  regurgitation 
(j).  198),  there  are  seven  basic  murmurs  heard  only,  or 
loudest,  over  the  aortic  interspace,  and  are  consequently 
referable  to  the  aortic  orifice,  the  aorta  itself,  or  the 
left  ventricle.  Five  of  these  murmurs  are  systolic  in 
time,  and  two  diastolic.  The  five  systolic  murmurs 
are  the  aortic  obstructive,  intra-arterial,  intra- ventricu- 
lar, dynamic,  and  cardio-resi3iratory.  Of  these,  the 
aortic  obstructive,  intra-arterial,  and  intra- ventricular 
murmurs  are  organic,  the  dynamic  and  cardio-respira- 
tory  being  inorganic,  or  functional.  The  diastolic  mur- 
murs in  this  case,  as  in  others,  are  always  organic.  Of 
these  seven  aortic  basic  murmurs,  therefore,  five  are 
organic  and  two  are  inorganic,  or  functional.  Compare 
the  following  table: 


Aoi'tic  Basic 
Murmuis 


Sytolic 


Diastolic 


Aortic  Obstructive. 
Iiitni-Artei'ial. 
Intra- Vontriciilar. 
Dynamic    i  Neurotic  Origin. 
(  Due  to  Anaemia. 
^  Cardio-respiratory. 

j  Aortic  Regurgitant. 

(  Intra-Arterial  (aortic  non- regurgitant). 


By  comparing  this  table  with  that  of  mitral  aj)ex 
murmurs  (p.  198),  we  have  here,  in  addition,  the  intra- 
arterial 111 II rill urs.     We  also  have  the  aortic  systolic 


AORTIC    OBSTRUCTION.  22'S 

obstructive  murmur  in  place  of  tlie  mitral  systolic  re- 
gurgitant murmur,  and  tlie  aortic  diastolic  regurgitant 
instead  of  the  mitral  i^r^esystolic  (or  diastolic,  as  it  is 
called  by  Guttmann)  obstructive  murmur.  In  other 
words,  the  mitral  regurgitant  and  aortic  obstructive 
murmurs  are  systolic,  while  the  mitral  obstructive  and 
aortic  regurgitant  are  chiefly  diastolic  in  time. 

Aortic  Obstruction. 

Aortic  obstruction  (constriction,  stenosis)  is  the  cause 
of  enlargement  of  only  the  left  ventricle,  as  a  rule.  It 
is  the  least  harmful  of  all  valvular  lesions.  The  reason 
for  enlargement  of  the  left  ventricle  in  this  disease  is 
obvious,  as  it  has  more  work  to  do  to  drive  blood 
through  the  obstructed  aortic  orifice,  and  the  degree  of 
enlargement  will  be  in  projDortion  to  the  amount  of  ob- 
struction. The  second  sound  over  the  pulmonary  inter- 
space remains  normal,  as  the  right  ventricle  is  not  af- 
fected, but  the  second  sound  over  the  aortic  interspace 
is  weak,  owing  to  the  obstruction  and  diminished 
amount  of  blood  thrown  into  the  aorta.  The  first 
sound  at  the  apex  may  be  strong.  The  radial  pulse  is 
regular,  as  a  rule,  but  in  marked  cases  it  is  small, 
hard,  and  rigid.     The  physical  signs  are : 

Inspection. — The  apex-beat  is  displaced  downward 
and  outward  from  its  normal  locality,  in  proportion  to 
enlargement  of  the  left  ventricle.  The  cardiac  impulse 
is  usually  seen  to  be  more  forcible  than  normal. 

Palpation.— The  apex-beat  is  felt  to  be  somewhat 
displaced  downward  and  outward,  and  to  be  increased 
in  force.     Basic  systolic  thrill  is  sometimes  felt,  but 


224  PHYSICAL    DIAGNOSIS. 

only  in  those  cases  where  dilated  hypertrophy  is  well 
marked. 

Percussion. — The  area  of  dullness  is  enlarged,  es- 
pecially the  area  of  suj^erhcial  dullness,  and  the  quality 
is  more  markedly  dull,  of  course,  in  proportion  to  the 
amount  of  cardiac  enlargement  and  disx)lacement  of 
pulmonary  tissue. 

Auscultation. — The  first  sound  is  usually  normal  or 
louder,  but  the  second  sound  over  the  aortic  interspace 


/iV 


Fig.  27. — Aortic  Obstruction  and  iiegurgitatiou,  showing  Enlargement  of  Left 
Ventricle. 


is  weak,  for  reasons  already  given.  A  systolic  basic 
murmur  is  heai-d,  which  has  various  names,  such  as 
aortic  direct,  obstructive,  stenotic,  and  so  on.  This 
aortic  obstructive  (direct,  stenotic,  constrictive,  sys- 
tolic) murmur  is  heard  loudest,  not  directly  over  the 
site  of  the  aortic  valves  (p.  188),  but  over  the  aortic  or 
second  interspace  near  the  right  edge  of  the  sternum, 
where  the  most  pronnnent  joart  of  the  bulge  of  the 
aorta  lies  (Gray).  The  murmur  is  systolic  in  time,  like 
the  mitral  regurgitant,  and  occurs  with  the  first  sound, 


AORTIC    OBSTRUCTION.  225 

or  rather  just  before  the  second.    It  may  be  represented 
by  the  following  diagram : 

nv  vh-       ^iic 


A7^ea  of  Transmission. — Though  heard  loudest  over 
the  aortic  interspace,  the  murmur,  if  loud  enough,  and 
is  caught  up  by  the  sternum,  may  be  transmitted  along 
that  bone  from  one  end  of  it  to  the  other.  Besides 
this,  it  is  often  conveyed  by  the  arteries  into  the  neck, 
and  sometimes  may  even  be  heard  behind  over  the 
aorta  on  the  left  side  of  the  spinal  column.  If  it  be 
loud  enough,  as  when  it  is  musical  sometimes,  it  may 
be  heard  all  over  the  chest.  In  rare  cases  it  is  heard 
equally  loudly  over  the  pulmonary  interspace,  simply 
because  the  pulmonary  artery  takes  up  the  sound  from 
the  aorta,  owing  to  their  unusual  proximity.  But  if 
the  murmur  is  very  feeble  it  will  with  difficulty  be 
heard,  even  at  the  aortic  interspace  as  sometimes  hap. 
pens.  The  loudness  or  feebleness  of  the  murmur  will 
give  little  or  no  true  idea  of  the  real  extent  of  the 
lesion.  The  murmur  is  rendered  more  distinct  by 
walking  rapidly,  or  in  case  there  be  co-existing  anae- 
mia. In  all  cases  of  doubt  as  to  whether  a  murmur  be 
present  or  not  it  is  well  to  have  the  patient  walk  brisldy 
up  and  down  the  room  several  times,  and  then  auscul- 
tate immediately  upon  stopping.  Sometimes,  however, 
a  purely  dynamic  murmur  may  be  j)roduced  by  this 
means. 

Diagnosis  of  Aortic  Obstruction. — There  are  other 

systolic  murmurs  to  be  heard  at  the  base  that  very 

closely  resemble  the  true  aortic  obstructive,  just  as 

there  are  systolic  murmurs  at  the  apex  to  imitate  the 
15 


226  PHYSICAL    DIAGNOSIS. 

true  mitral  regurgitant.  Omitting  the  pericardial  and 
cardio-pleuritic  adventitious  sounds  already  differen- 
tiated when  speaking  of  mitral  regurgitation  (p.  206), 
there  remain  the  (1)  intra-arterial  and  (2)  intra- veii- 
tricular  organic  murmurs,  besides  the  inorganic,  or 
functional  murmurs,  (3)  the  djTiamic,  and  (4)  the  cai- 
dio-respiratory. 

(1)  Intra-arterial  Murmurs.- — These  are  organic  sys- 
tolic basic  murmurs,  due  to  roughening  of  the  lining 
membrane  of  the  ascending  portion  of  the  aorta,  in- 
flammatory vegetations,  co-arctation  (bending  together) 
of  the  aorta,  slight  constriction,  sacculation  or  pouch- 
ing of  the  vessel  near  the  heart,  and  i)ressure  on  the 
aorta  near  its  origin  from  tumors  or  fluid  in  the  jDeri- 
cardial  sac.  Though  sufficient  to  produce  a  systolic 
basic  murmur,  they  might  not  materially  interfere  with 
the  outward  flow  of  blood,  so  that  the  left  ventricle  is, 
in  such  cases,  not  usually  enlarged,  whereas  in  aortic 
obstruction,  unless  of  very  recent  occurrence,  it  is  en- 
larged. Where  no  enlargement  is  observable,  the  his- 
tory of  a  recent  attack  of  endocarditis  would  be  of 
service;  otherwise,  it  might  be  difficult,  if  not  impossi- 
ble, to  make  an  absolutely  correct  diagnosis,  even  by 
the  pulse  as  traced  with  the  spliygmograph,  since  it  is 
but  little  altered  in  aortic  obstruction.  Intra-arterial 
murmurs  are  invariably  loudest  over  the  site  where 
they  are  produced,  as  in  case  of  aneurismal  murmurs. 
It  might  so  happen  that  the  cause  of  the  murmur 
might  be  situated  in  the  pulmonary  artery,  but  caught 
up  by  the  aorta.  For  that  reason,  it  is  thought  better 
to  term  them  intra-arterial  than  intra-aortic  murmurs. 

(2)  Intra-ventricidar  J/^^rmtirs.— The  same  remarks 


AORTIC    OBSTllUCTION.  227 

apply  here  as  when  speaking  of  mitral  regurgitation, 
(p.  206).  Instead  of  the  aortic  orifice  being  affected  by 
the  endocarditis,  a  lesion  somewhere  within  the  ventri- 
cle ( intra- ventricular)  may  have  been  produced,  suffi- 
cient to  give  rise  to  a  systolic  murmur,  heard  only,  or 
loudest,  over  the  aortic  interspace.  It  is  differentiated 
from  aortic  obstruction,  not  by  the  quality,  pitch,  or 
other  properties  of  the  murmur,  but  by  the  fact  that  if 
the  murmur  be  purely  intra-ventricular,  the  left  ventri- 
cle is  not  enlarged. 

(3)  Dynamic  Murmurs. — These  murmurs  are  caused 
by  perverted  action  of  the  heart,  and  may  be  of  neurotic 
or  anaemic  origin,  as  described  when  speaking  of  them 
in  connection  with  mitral  regurgitation  (p.  207),  They 
occur  more  commonly  at  the  base  than  the  apex,  but 
are  always  systolic  in  both  localities.  In  a  word,  dias- 
tolic heart  murmurs  are  organic,  and  all  functional,  or 
inorganic  murmurs  are  systolic. 

These  dynamic  aortic  systolic  murmurs  of  neurotic 
origin  are  distinguished  here,  as  elsewhere,  by  their 
being  inconstant.  They  are  observed  not  only  among 
the  choreic,  nervous,  and  hysterical,  but  often  among 
athletes,  during  or  immediately  after  violent  exercise. 
A  perfectly  healthy  person,  esioecially  a  young  girl, 
after  violently  running  up  steps,  will  often  have  a  tem- 
porary dynamic  basic  aortic  systolic  murmur.  Some- 
times it  is  pulmonic  also.  A  murmur  may  be  some- 
times produced,  also,  with  pressure  of  the  stethoscope 
with  those  having  thin  and  yielding  chest  walls,  as 
among  children.  Such  dynamic  murmurs  are  told  by 
their  being  inconstant,  and  by  their  not  being  neces- 
sarily associated  with  hypertrophy  of  the  left  ventricle. 


228  PHYSICAL    DIAGNOSIS. 

Dynamic  aortic  systolic  murmurs  may  also  be  due 
to  anaemia,  as  in  the  case  of  apex  murmurs.  Tliey  are 
distinguished  by  their  not  being  necessarily  associated 
with  the  left  ventricular  enlargement;  by  other  and 
co-existing  signs  of  anaemia,  of  which  venous  hum 
(soon  to  be  fully  described)  is  one"  of  the  most  impor- 
tant ;  by  the  non-existence  of  other  murmurs ;  and  by 
their  disappearing  under  projner  treatment  for  anaemia. 

(4)  Cardio-respiratory  murmurs,  so-called,  are 
thrown  out  by  having  the  patient  hold  the  breath,  and 
they  then  cease  at  once,  as  already  described  when 
sj)eaking  of  mitral  regurgitation  (which  see).  The 
aortic  regurgitant  murmur,  having  a  different  area  of 
transmission,  and  occurring  in  diastolic  time  instead  of 
systolic,  besides  other  signs  to  be  described,  need  not 
be  dwelt  upon  here.  Sometimes  aortic  obstruction  is 
so  marked  that  the  left  ventricle  will,  in  time,  become 
so  enlarged  as  to  cause  the  mitral  valves  to  be  some- 
what relatively  insufficient,  giving  a  slight  mitral  sys- 
tolic regurgitant  murmur  at  the  apex;  but  this  con- 
dition appears  to  be  somewhat  rare. 

Anaemic  murmurs  are  usually  placed  here,  so  that  a 
few  remarks  in  regard  to  them  at  once  become  neces- 
sary. According  to  some  authors,  they  are  always 
produced  at  the  aortic  orifice.  The  theory  is  that  in 
anaemia  the  heart  muscle  becomes  weak  and  flabby, 
and  stretches  so  that  the  cavities  of  the  heart  are 
larger  than  normal,  while  the  tough  rings  around  the 
orifices  remain  the  same.  Enlarged  cavities,  the  ori- 
fices remaining  normal,  is  relatively  the  same  thing  as 
normal  cavities  and  constricted  orifices,  so  that  such  a 
so-called  anaemic  murmur  is,  after  all,  simply  a  sort  of 


AORTIC    OBSTRUCTION.  229 

temporary  obstruction  murmur,  in  other  words,  a  dy- 
namic murmur  due  to  anaemia,  and  not  j)urely  a  blood, 
or  lisemic  murmur. 

Purely  hsemic  murmurs,  due  to  anaemia,  are  heard 
over  the  pulmonary  interspace  rather  than  the  aortic. 
Sometimes,  it  is  true,  they  are  caught  up  by  the  aorta, 
just  as  aortic  organic  obstructive  murmurs  are  some- 
times caught  up  by  the  pulmonary  artery  when  the 
two  press  closely  on  each  other.  'Not  only  are  these 
I)ulmonary  hsemic  murmurs  sometimes  caught  up  by 
the  aorta,  but  by  it  they  may  be  and  are,  sometimes, 
conveyed  into  the  arteries  of  the  neck.  Frequently, 
these  murmurs  in  the  arteries  of  the  neck,  however, 
are  not  conveyed  there,  but  are  simply  created  by 
pressure  from  the  stethoscope  disturbing  the  regular- 
ity of  the  calibre  of  the  artery. 

How  are  basic  dynamic  murmurs  due  to  anaemia  to 
be  distinguished  from  aortic  obstructive  murmurs, 
both  being  systolic?  IN'ot  by  their  quality,  pitch,  or 
other  properties,  albeit  murmurs  dependent  on  anaemia 
for  their  production  are  usually  lower  in  pitch,  softer, 
more  blowing  in  quality,  and  more  diffused  about  the 
base  of  the  heart,  but  are  not  transmitted  so  far  as  in 
the  case  of  obstruction.  But  this  is  not  always  the 
case.  The  real  difference  is  that  aortic  obstruction 
causes  enlargement  of  the  left  ventricle,  whereas  anae- 
mia does  not,  although  palpitation  from  chronic  anae- 
mia may  give  rise  to  a  somewhat  general  enlargement 
of  the  heart  from  overwork  long  continued.  Or  else 
the  enlargement  Avould  be  due  to  dilatation  from  anae- 
mia, with  feeble  impulse,  but  in  either  case  it  would 
be  general  instead  of  limited  to  the  left  ventricle,  as  is 


230  I'JIYSICAL    DIAGNOSIS. 

usually  the  case  in  aortic  obstruction.  Only  in  rare 
cases  of  long  standing  does  aortic  obstruction  give  rise 
to  relative  (secondary)  mitral  regurgitation  with  se- 
quential enlargement  of  the  left  auricle  and  right  ven- 
tricle. Dynamic  murmurs,  due  to  anaemia,  whether 
heard  at  the  ai)ex  or  base,  are  also  associated  with 
other  signs  of  anaemia,  among  which  venous  hum  may 
be  mentioned  here. 

Venous  hum.,  or  bruit  de  diahle,  is  a  continuous 
though  remittent  roaring  sound,  heard  over  certain 
large  veins,  as  the  jugulars,  subclavian,  and  femoral 
veins.  From  the  fact  that  the  sound  is  continuous  it 
is  readily  distinguished  from  an  arterial  murmur.  It 
is  most  convenient  to  listen  for  it  in  the  neck,  and  it  is 
best  heard  over  the  junction  of  the  internal  jugular 
and  subclavian  veins.  Turn  the  patient's  head  to  one 
side  and  elevate  the  chin,  so  as  to  render  the  tissues 
tense  on  that  side  of  the  neck.  Now  place  the  stetho- 
scope over  the  point  mentioned,  just  at  the  root  of  the 
neck,  and  the  continuous  roar  of  venous  hum  (not 
rhythmical  tracheal  breathing)  will  be  distinctly  heard, 
usually  in  an  anaemic  person,  especially  a  young  anae- 
mic woman.  Pressure  with  the  finger,  or  otherwise, 
over  the  vein  on  the  distal  side  of  the  stethoscope 
causes  the  hum  to  cease  at  once.  Remove  the  pressure 
and  it  immediately  returns. 

Guttmann,  of  Berlin,  thinks  that  venous  hum  is  due 
to  the  vortiginous  (eddying,  whirling)  movement  of 
blood  in  the  ampulhe  (bidbs)  formed  by  the  union  of 
the  internal  jugular  and  subclavian  veins.  The  volume 
of  blood,  he  thinks,  is  smaller  in  anaemia,  and  the  am- 
l)ull{e  remain  the  same  size,  as  they  are  adherent  to 


AORTIC    OBSTRUCTION.  231 

the  surrounding  connective  tissue.  This  would  allow 
space  in  the  ampulhe  for  the  vortiginous  or  eddying 
movement  of  the  blood,  as  mentioned.  According  to 
Guttmann,  venous  hum  is  also  heard  more  frequently 
and  with  greater  intensity  on  the  patient's  left  side  of 
the  neck,  since  the  curved  direction  that  the  blood  has 
to  take  on  the  left  side  would  produce  more  vortiginous 
movement.  Not  infrequently,  however,  it  is  heard 
loudest  on  the  patient's  right  side  of  the  neck,  and 
sometimes,  indeed,  when  it  cannot  be  heard  at  all  on 
the  left.  In  the  first  place,  it  is  highly  improbable  that 
the  ampullae  would  be  prevented  from  contracting,  and 
becoming  accommodated  to  the  diminished  volume  of 
blood,  by  their  being  adherent  to  surrounding  and 
rather  loose  connective  tissue.  In  the  second  place, 
venous  hum  does  not  appear  to  be  due  to  the  vortigi- 
nous movement  of  venous  blood,  since  it  is  produced 
best  where  the  blood  has  a  straight  and  rapid  course  in 
large  veins,  and  for  that  reason  is  heard  best,  or  only, 
on  the  right  side  of  the  ]3atient's  neck.  There  are  vari- 
ous other  theories  about  the  production  of  venous 
hum. 

According  to  Fothergill,  many  ingenious  hypotheses 
have  been  raised  regarding  the  causation  of  venous 
hum,  but  none  as  yet  have  been  accepted.  According 
to  Walshe,  the  comj^osition  of  the  blood  in  the  ansemic 
state  cannot  be  overlooked.  It  appears  that  watery 
venous  blood  is  soniferous,  while  arterial  blood,  under 
the  same  conditions,  is  not,  the  exact  reason  for  which 
does  not  apiDear  to  be  known.  It  would  seem,  there- 
fore, that  venous  hum  depends  upon  the-  character  of 
the  venous  blood  in  the  anaemic  state,  rather  than  upon 


232  PHYSICAL    DIAGNOSIS. 

the  supposed  vortiginons  movement  of  the  blood  in 
ampullae,  the  vibration  of  valves  of  veins,  and  so  on. 

Aortic  Regurgitation. 

Aortic  regurgitation  (reflux,  insufficiency)  is  the 
cause  of  great  enlargement  of  the  left  ventricle  only, 
as  a  rule.  Should  relative  insufficiency  of  the  mitral 
valves  occur,  the  left  auricle,  and,  in  time,  possibly,  the 
right  ventricle  also,  would  become  enlarged,  though 
the  patient  would  hardly  live  long  enough  in  such  a 
marked  case.  It  is  one  of  the  most  hopeless  and 
fatal  of  all  valvular  lesions  of  the  heart.  Walshe 
places  it  fourth  in  the  order  of  relative  gravity,  but, 
leaving  out  tricuspid  regurgitation,  I  should  be  in- 
clined to  place  it  first. 

The  reason  why  the  left  ventricle  becomes  enlarged 
in  aortic  regurgitation  is  obvious.  The  blood  regurgi- 
tating back  into  tlie  ventricle  simply  gives  it  double 
w^ork  to  perform.  The  first  sound  of  the  heart  may  he 
louder  than  normal,  or  it  may  be  absent.  In  other 
words,  it  varies,  dex)ending,  no  doubt,  upon  the  amount 
of  dilatation  and  whether  or  not  it  has  brought  about 
relative  mitral  insufficiency.  The  second  sound  over 
the  pulmonary  intersj)ace  is  usually  normal,  unless  the 
right  ventricle  becomes  sequentially  enlarged  from  rela- 
tive insufficiency  of  the  mitral  valves,  and  then  the 
second  sound  over  the  pulmonary  interspace  will  be 
accentuated.  Over  the  aortic  interspace  the  second 
sound  is  taken  up  by  the  aortic  regurgitant  murmur 
which  occurs  with  it,  being  diastolic  in  time.  The 
pulse  of  aortic  regurgitation  is  characteristic.  Owing 
to  enlargement  of  the  left  ventricle,  the  blood  is  driven 


AORTIC    REGURGITATION. 


233 


with  great  force  into  the  aorta,  })iit  as  that  artery 
empties  itself  in  two  directions  at  once,  back  into  the 
left  ventricle  and  forward  into  the  cajjillaries,  the  pidse, 
which  started  with  such  a  thump,  suddenly  collapses 
from  not  being  sustained,  so  that  it  is  sometimes  called 
collapsing,  vanishing,  unsustained,  locomotive,  or  water- 
hammer  2-)nlse,  There  are  various  names  by  which  it  is 
known,  and  w^e  have  good  authorities  for  them,  but  it 
would  appear  that  v^ater-hammer  is  the  one  now  most 
commonly  used.  The  physical  signs  of  aortic  regurgi- 
tation are:     (See  fig.  for  Aortic  Obstruction.) 

Inspection. — The  apex-beat  is  carried  down  and  out, 
owing  to  enlargement  of  the  left  ventricle.  The  heart's 
imjDulse  is  usually  seen  to  be  more  forcible  than  nor- 
mal. There  is  usually  pulsation  in  the  arteries  about 
the  neck,  and  all  over  the  body  where  the  arteries  are 
superficially  located  and  visible.  If  the  patient  be  di- 
rected to  hold  the  arm  up,  not  infrequently  the  radial, 
ulnar,  and  other  arteries  of  the  upper  extremity  are 
seen  to  pulsate  as  in  arterial  sclerosis. 

Palpation. — ^The  apex  of  the  heart  is  felt  disjDlaced 
downward  and  outward,  and  sometimes  basic  diastolic 


Fig.  28.— Sphygmograpliic  Tracing  of  Aortic  Regurgitation  Pulse. 

thrill  is  felt.  The  radial  pulse  is  unsustained,  or  col- 
lapses under  the  finger.  The  sphygmograpliic  tracings 
of  this  impulse  are  characteristic. 

Percussion.— HYns,  shows  an  increased  area  of  cardiac 


234  PHYSICAL    DIAGNOSIS. 

dnllness,  due  to  enlargement  of  the  left  ventricle.  It 
may  be  still  more  increased  if  there  be  relative  mitral 
insufficiency  and  consequent  enlargement  of  the  left 
auricle  and  also  right  ventricle. 

Auscultation. — This  reveals  the  presence  of  the  char- 
ticteristic  aortic  regurgitant  murmur.  It  is  diastolic 
in  time,  and  occurs  with,  or  takes  the  place  of,  the  sec- 
ond sound  of  the  heart.  It  is  sometimes  termed  the 
aortic  indirect  or  insufficient  murmur.  The  aortic  re- 
gurgitant (indirect,  insufficient,  diastolic)  murmur  may 
be  represented  by  the  following  diagram : 

up           tn-j)h 
I 1  •  I 1  -I 

The  quality  of  the  murmur  varies,  but  in  most  cases 
it  apj)ears  to  be  harsher  and  higher-pitched  than  the 
aortic  obstructive  murmur.  Sometimes  they  exist  to- 
gether, forming  what  may  be  termed  steam-tug  mur- 
mur, /wo — cJiee.  The  combination  is  usually  best  heard 
on  the  sternum  about  the  fourth  or  lifth  cartilage. 

Area  of  Transmission. — The  aortic  regurgitant  mur- 
mur is  directed  back  from  the  current  of  blood,  and-  for 
that  reason  is  not  usually  heard  so  plainly  in  the  aortic 
interspace  as  it  is  over  the  sternum  about  the  fourth 
cartilage.  It  is  sometimes  heard  onl^^  at  the  lower  end 
of  the  sternum.  Sometimes  it  is  conveyed  backward  to 
the  apex  of  the  heart,  where  it  is  to  be  distinguished 
by  its  diastolic  time,  diminished  intensity,  and  the  en- 
larged left  ventricle,  from  mitral  obstructive  murmur- 
(which  see).  If  the  murmur  is  loud  enough,  the  ster. 
num  will  catch  up  the  sound,  so  that  it  may  be  heard 
from  one  end  of  that  bone  to  the  other.  Occasionally, 
the  pidmonai'y  artery  takes  up  the  murmur  from  its 


AORTIC  OBSTRUCTIOX  A^^D  IlEGURGITATION^.        235 

j)roximity  to  tlie  aorta,  so  that  pulmonary  regurgita- 
tion may  be  imitated  (p.  239).  Sometimes  it  is  heard 
behind  along  the  spinal  column,  but  it  may  be  loud 
and  musical,  so  as  to  be  heard  as  soon  as  one  enters 
the  room,  and  may  be  so  audible  to  the  patient  as  to 
prevent  sleep. 

Diagnosis  of  Aortic  Regurgitation. — This  is  based 
upon  the  characteristic  unsustained  (water-hammer, 
collai^sing,  locomotive)  aortic  regurgitant  pulse,  en- 
largement of  the  left  ventricle,  and  the  accompanying 
diastolic  regurgitant  murmur.  The  latter,  in  rare 
cases,  may  be  imitated  by  a  murmur  caused  by  rough- 
ness with  dilatation  of  the  ascending  portion  of  the 
aorta.  The  late  Dr.  Austin  Flint  speaks  of  this  as  an 
aortic  diastolic  non-regurgitant,  or  prediastolic,  mur- 
mur. It  is  usually  preceded  by  an  aortic  direct  mur- 
mur, but  not  always.  This  imitative  murmur  is  not 
necessarily  associated  with  enlargement  of  the  left  ven- 
tricle, and  the  pulse  characteristic  of  aortic  regurgita- 
tion is  wanting.  These  diastolic  murmurs  may,  in  rare 
cases,  be  heard  only  at  the  lower  end  of  the  sternum, 
like  tricusxDid  regurgitation,  but  the  latter  being  sys- 
tolic in  time,  the  diagnosis  is  easy. 

Aortic  Obstruction  and  Regurgitation. 

This  combination  of  lesions  is  second  in  the  order  of 
frequency,  according  to  Walshe.  Separately  or  to- 
gether, they  cause  enlargement  of  the  left  ventricle. 
When  both  lesions  exist  at  the  same  time,  the  left  ven- 
tricle is  enlarged  and  there  are  two  murmurs,  the  sys- 
tolic obstructive  and  the  diastolic  regurgitant  already 
described.    The  two  are  often  heard  together,  especially 


286  PHYSICAL  diaujS"0!sis. 

on  the  sternum,  usually  about  the  fourth  or  lifth  car- 
tilage, and  form  what  may  be  termed  the  steam-tug 
murmur,  lioo — cliee^  hoo  standing  for  the  obstructive, 
and  chee  for  the  regurgitant  murmur. 

Pulmonary  Murmurs. 

We  listen  over  thQ  apex,  ensiform  cartilage,  and 
aortic  interspace,  respectively,  for  mitral,  tricuspid, 
and  aortic  murmurs  in  their  maximum  intensity.  We 
now  come  to  the  fourth  and  last  point  on  the  front  of 
the  chest  walls,  the  pulmonary  intersx)ace,  where  we 
listen  for  pulmonary  murmurs  in  their  maximum  in- 
tensity. The  pulmonary  interspace  is  the  second  inter- 
sjjace,  or  the  interspace  between  the  second  and  third 
costal  cartilages,  at  the  left  edge  of  the  sternum.  Theo- 
retically, we  would  have  the  same  number  of  murmurs 
here  as  over  the  aortic  interspace,  with  the  addition  of 
the  purely  anaemic  or  haemic  murmur.  But  pulmonic 
diastolic  regurgitant  murmur  is  so  rare  that  it  may  be 
X)ractically  thrown  out  altogether.  Of  the  systolic  pul- 
monary murmurs  the  same  remarks  would  ajiply  here 
to  intra-ventricular,  intraarterial,  dynamic,  and  cardio- 
respiratory murmurs,  as  when  describing  aortic  systolic 
murmurs.  There  remain  two  pulmonary  murmurs, 
therefore,  the  pulmonary  obstructive,  and  the  aniemic. 

Pulmonary  Obstruction. 

Pulmonary  obstruction  (constriction,  stenosis)  is  not 
commonly  observed  among  adults.  It  is  due  to  foetal 
endocarditis  in  which  the  right,  instead  of  the  left  side 
of  the  heart  is  affected,  as  already  stated  (p.  193). 
Children  are  therefore  born  with  pulmonary  valvular 


PULMONAKY    OBSTRUCTIOX.  287 

lesions,  when  they  have  them,  and  usually  die  early.  It 
gives  rise  to  a  basic  systolic  murmur,  as  in  the  case  of 
aortic  obstruction,  but  heard  on  the  left  side  of  the 
sternum  over  the  j)ulmonary  (second)  interspace  in  its 
maximum  intensity,  instead  of  on  the  right.  The  pulse 
is  not  affected  by  it.  It  leads  to  more  or  less  enlarge- 
ment of  the  right  ventricle.  The  diagram  representing 
this  murmur  is  the  same  as  for  aortic  obstruction. 

The  area  of  transmission  is  the  same  as  for  the  aortic 
obstructive  murmur  so  far  as  the  sternum  is  concerned, 
but  beyond  that  it  differs  materially.  It  is  not  con- 
veyed up  into  arteries  of  the  neck,  but  back  in  the 
lungs  by  the  pulmonary  artery,  and  for  that  reason, 
when  loud,  is  heard  behind  over  both  sides  of  the  backs 
of  children  having  thin  chest  walls.  It  is  also  trans- 
mitted out  toward  the  left  shoulder  sometimes.  In  a 
case  of  a  girl  of  fourteen  now  under  my  observation, 
the  murmur  is  so  loud  as  to  be  heard  distinctly  all  over 
the  chest,  though  loudest  and  most  distinct  over  the 
pulmonary  interspace.  Systolic  basic  thrill  is  some- 
times felt,  as  in  aortic  obstruction. 

How  are  we  to  tell  it  from  the  anaemic  or  other  mur- 
mur? Simply  because  it  is  usually '  associated  with 
more  or  less  cyanosis  or  blue  disease  (morbus  cseru- 
leus),  owing  to  the  venous  congestion  over  the  body. 
Walshe  says  that  true  pulmonary  obstructive  murmur 
is  very  rare,  except  in  cases  of  cyanosis.  Fits  of  dysp- 
noea are  likely  to  occur  any  time,  owing  to  the  lungs 
not  being  properly  supxDlied  with  blood.  Cyanosis  it- 
self does  not  give  rise  to  a  murmur  as  anaemia  does. 

True  anaemic  or  haemic  murmurs  due  to  a  watery 
condition  of  the  blood  are  always  systolic,  and  perhaps 


288      '  PHYSICAL    DIAGNOSIS. 

always  basic.  They  are  also  apparently  pulmonic  in- 
stead of  aortic,  although  they  may  sometimes  be  taken 
up  by  the  aorta  when  the  two  vessels  are  in  close  con- 
tact with  each  other.  May  not  these  murmurs  be 
nothing  more  than  venous  hum  in  the  pulmonary 
artery,  thrown  into  rhythm  by  j)roximity  to  the  heart? 
It  is  true  that  they  do  not  always  co-exist  with  venous 
hum  in  the  neck,  but  that  may  be  because  the  venous 
blood  travels  differently  in  those  vessels. 

Another  supposed  cause  of  systolic  anaemic  murmurs 
heard  over  the  pulmonary  interspace  would  not  be 
mentioned  here  but  for  the  fact  that  Balfour's  name  is 
connected  with  it,  although,  according  to  Flint,  it  did 
not  originate  with  Balfour,  but  with  Naunyn.  The 
latter  thought  that  the  murmur  was  not  to  be  attrib- 
uted to  the  pulmonary  orifice  at  all,  biit  was  due  to  a 
slight  mitral  regurgitation  due  to  weakness  of  the 
heart  from  anaemia,  with  an  accompanying  mitral 
systolic  anaemic  murmur,  not  loud  enough  to  be 
heard  at  the  apex  but  loud  enough  to  be  taken  ui3  by 
the  left  auricular  appendix,  which  had  also  become 
dilated  and  enlarged  from  anaemia!  Yet  in  mitral 
regurgitation  with  a  loud  murmur  and  the  left  auricle 
very  much  more  enlarged  than  in  anaemia,  the  trans- 
mission of  the  murmur  to  this  point  is  very  rare,  as 
already  stated  (see  Mitral  Regurgitation).  Flint,  per- 
hai)s  Justly,  characterizes  such  reasoning  as  strained. 
Vierordt,  of  Leij^sic,  states  that  the  exjilanation  of. 
these  cardiac  anaemic  murmurs  is  very  difficult,  and 
thinks  that  in  many  cases  Sable's  suggestion  might  be 
available,  that  these  murmurs  may  arise  from  the  large 
vessels  concealed  in  the  thorax. 


pulmonary  regurgitation.  289 

Pulmonary  Regurgitation. 

Pulmonary  regurgitation  (reflux,  insufficiency)  is 
such  a  rare  disease  tliat  it  is  hardly  v/orth  mentioning. 
If  it  occurred  it  would  give  rise  to  a  j)nlmonary  regur- 
gitant murmur,  which  would  be  diastolic  in  time,  and 
could  not  be  confounded  with  any  functional  or  inor- 
ganic murmur.  As  Flint  states,  a  diagnosis  could  be 
made  when  other  signs  went  to  show  the  existence  of 
pulmonary  and  the  absence  of  aortic  regurgitation. 
Diastolic  thrill  might  be  felt  in  both.  But  the  pulse,  of 
course,  would  be  different,  being  unaffected  by  pul- 
monary regurgitation,  and  collapsing  in  the  aortic 
lesion.  Jugular  pulsation  would  occur  in  time,  with 
enlargement  of  the  right  ventricle  in  pulmonary  regur- 
gitation, together  with  cyanosis  and  cardiac  dropsy, 
none  of  which  are  characteristic  of  aortic  regurgitation. 
As  the  disease  is  so  rare,  however,  it  is  perhaj)s  really 
more  of  a  clinical  curiosity  than  of  any  practical  value. 

Relative  Gravity  of  Valvular  Lesions. 

According  to  AValshe,  the  following  is  the  order  of 
relative  gravity  of  valvular  lesions:  (1)  tricuspid  re- 
gurgitation, (2)  mitral  regurgitation,  (3)  mitral  obstruc- 
tion, (4)  aortic  regurgitation,  (o)  pulmonary  obstruction, 
(6)  aortic  obstruction.  Yery  little  is  known  about  pul- 
monary regurgitation  and  tricuspid  obstruction. 

Neither  of  the  first  three  mentioned  i:)roduce  what  is 
generally  understood  as  sudden  death  from  heart  dis- 
ease. But  all  three  are  dangerous,  from  such  complica- 
tions as  pulmonary  congestion,  hemorrhagic  infarction 


240  PHYSICAL    DIAGNOSIS. 

(p.  101),  cardiac  dropsy,  and  pulmonary  oedema,  which 
are  likely  to  occur.  But  in  aortic  regurgitation  not 
only  is  thoracic  aneurism  likely  to  be  j^roduced  from 
the  tremendous  force  with  which  the  blood  is  thrown 
into  the  aorta  (p.  271),  and  sudden  death  from  cerebral 
apoplexy,  but  there  is  also  liability  to  sudden  death  due 
to  failure  of  the  heart's  action  from  some  cause,  sup- 
posed to  be,  by  some,  failure  of  blood  to  be  conveyed 
by  the  nutrient  arteries  of  the  heart.  For  these  reasons 
it  would  appear  that  aortic  regurgitation,  well-marked, 
is  among  the  most  dangerous  of  all  valvular  lesions  of 

the  heart. 

Endocaeditis. 

Endocarditis,  as  already  said,  occurs  most  frequently 
in  the  course  of  acute  articular  rheumatism,  especially 
among  the  young,  but  it  may  also  occur  in  the  course 
of  any  other  disease,  or  independently.  During  foetal 
life  it  attacks  the  right  side  of  the  heart,  but  after  birth 
it  attacks  the  left  side,  as  already  stated  (p.  193).  It 
usually  results  in  valvular  disease  of  some  kind  (mitral 
regurgitation,  most  frequently  with  consequent  enlarge- 
ment), or  else  some  lesion  elsewhere  within  the  ventri- 
cle, or  finally  it  may  possibly  end  in  complete  recovery. 

The  physical  signs  of  endocarditis  are  based  chiefly 
on  auscultation.  Inspection  usually  is  negative.  Pal- 
pation is  usually  also  negative,  but  may  reveal  the  fact 
that  the  heart's  action  and  pulse  are  excited,  and 
sometimes  irregular.  If  it  be  the  first  attack,  percus- 
sion dullness  will  be  very  slightly,  or  not  at  all,  in- 
creased in  extent,  as  the  heart  will  not  be  appreciably 
enlarged.  Upon  auscultation  the  sounds  Avill  be  nor- 
mal or  perhaps  slighth'  inci-ensed  in  intensity,  except 


PERICARDITIS.  241 

at  the  site  of  the  murmur,  which  will  be  heard  at  the 
apex  or  over  the  aortic  interspace.  The  mui-mur  occurs 
early  in  the  disease,  and  is  systolic  in  time  and  blowing 
in  quality.  It  is  due  to  roughening  of  the  surface  or 
deposit  of  lymph  on  or  near  the  valves  of  the  mitral  or 
aortic  orifices.  The  positive  proof,  according  to  Flint, 
is  the  presence  of  a  mitral  systolic  murmur  occurring 
during  an  attack  of  rheumatism  If  it  be  aortic  it  is  in 
many  cases  inorganic.  The  mitral  systolic  murmur 
need  not  show  actual  regurgitation  as  yet,  or  it  may 
be  purely  intra-ventricular.  But  if  the  left  ventricle 
be  eiilarged  and  endocarditis  be  suspected,  it  will  not 
be  the  first  attack,  since  the  enlargement  will  be  due  to 
mitral  regurgitation  from  a  previous  endocarditis. 

Pericarditis. 

Pericarditis  usually  occurs  in  connection  with  acute 
articular  rheumatism,  tubular  nephritis,  pleurisy, 
syiDhilis,  j)neumonia,  tubercle,  or  cancer.  Of  course  it 
may  be  due  to  surgical  injury  also,  but  it  is  rarely,  if 
ever,  an  idiopathic  affection.  It  is  usually  attended  with 
more  or  less  effusion,  and  is  divided  into  three  stages. 
In  the  first  stage  (congestion)  the  action  of  the  heart  is 
irritable  and  forcible.  The  area  of  dullness  is  as  yet 
unchanged.  Auscultation  uniformly  reveals  the  pres- 
ence of  a  pericardial  (exocardial)  friction  sound.  En- 
docardial murmurs  may  also  exist.  But  pericardial 
(exocardial)  friction  murmurs  are  superficial,  rubbing, 
churning,  clicking,  or  creaking,  never  blowing,  whis- 
tling, or  roaring,  and  are  limited  to  the  cardiac  region, 
and  often  vary  in  intensity  with  iDOsition  of  the  patient, 

or  pressure  w^ith  ear  or  stethoscope,  and  occur  inde- 
16 


242 


PHYSICAL    DIAGNOSIS. 


pendently  of  the  heart  sounds — that  is,  not  fixed. 
Endocardial  murmurs,  on  the  contrary,  are  fixed  in 
their  time  of  occurrence  with  regard  to  the  heart 
sounds,  and  are  often  conveyed  or  transmitted  over  cer- 


ii\. 


Fig.  29.— Diagram,  Pericarditis  with  Effusion. 

tain  areas,  as  already  described.      The  second  stage  of 
pericarditis  (effusion)  is  characterized  by  the  eifusion 
of  liquid— acute  hydro-pericarditis. 
Inspection  now  shows  prominence  of  the  pr^ecordial 


PERICARDITIS.  243 

region  in  proportion  to  tlie  amount  of  effusion,  dimi- 
nution, or  absence,  of  the  apex-beat,  and  diminution 
of  the  resr)iratory  movements  on  the  left  side. 

Palpation. — The  a^^ex-beat  is  raised  upward  and 
outward  to  the  left,  is  feeble  or  suppressed,  and  may 
change  with  position  of  the  patient.  If  not  felt  when 
the  patient  is  on  the  back,  it  may  be  perceptible  if  the 
patient  leans  forward.  An  undulating  impulse  is 
sometimes  felt,  and  the  epigastrium  may  be  bulging 
from  dex^ression  of  the  diaphragm. 

Percussion. — The  area  of  prsecordial  dullness  is  en- 
larged. If  the  effusion  be  great  this  area  is  found  to 
be  wider  below  than  above,  on  account  of  the  shape 
of  the  pericardial  sac.  It  may  extend  down  to  the 
seventh  rib  and  up  to  the  first  rib,  and  from  nipple  to 
nipple,  or  even  further. 

Auscultation. — The  pericardial  friction  sounds  have 
now  disa^opeared,  since  the  two  surfaces  cannot  rub 
together.  The  heart  sounds  are  feeble  and  heard  bet- 
ter at  the  top  of  the  sternum  than  elsewhere,  as  the 
effusion  occupies  less  space  there  than  below.  Some- 
times a  basic  systolic  murmur,  due  to  pressure  of  the 
effusion  on  the  aorta,  is  heard.  The  respiratory  mur- 
mur, pectorophony  (vocal  resonance),  and  vocal  fremi- 
tus are  diminished  or  absent  over  the  central  portion 
of  the  cardiac  region.  The  third  stage  is  that  of  ab- 
sorption. The  friction  sound  returns— /rz'c^zo  redux — 
the  heart  sounds  become  more  distinct,  and  there  is  a 
gradual  return  to  health  in  favorable  cases.  In  other 
cases  it  may  become  subacute  or  chronic. 

Chronic  pericarditis  may  be  attended  with  adhe- 
sions simx)ly,  or  there  may  be  adhesions  with  hypertro- 


244  PHYSICAL    DIAGNOSIS, 

phy  or  atrophy  (which  see),  or  there  may  be  chronic 
pericarditis  with  effusion,  termed  chronic  hydro-peri- 
carditis. The  physical  signs  of  chronic  hydro-pericar- 
ditis are  similar  to  those  of  the  acute  variety  just 
described. 

Pneumo-Jiydro-pericarditis,  air  and  fluid  in  the  peri- 
cardium, is  rare,  but  may  possibly  result  from  decom- 
position of  liquid  effusion,  or,  usually,  from  perforation 
communicating  with  the  oesophagus  or  lungs.  In  these 
cases  the  heart's  action  is  accompanied  by  metallic 
(amphoric)  tinkling,  amphoric  (metallic)  buzzing,  and 
splashing  like  a  water-wheel  (Walshe), 

HcBmo-pericardium,  or  blood  in  the  pericardium, 
may  result  from  cancer,  scurvy,  and  the  hemorrhagic 
tendency,  or  surgical  injury,  and  rupture  of  aneurism. 
If  the  patient  lived  long  enough  the  blood,  while  fluid, 
would  give  the  same  signs  as  hydro-pericarditis. 

Hydro-pericardium,  or  dropsy  of  the  pericardium, 
is  merely  associated  with  general  dropsy  from  Bright's 
disease  of  the  kidneys,  or  some  other  cause,  without 
inflammation  of  the  pericardium.  The  physical  signs 
are  those  of  hydro-pericarditis,  already  described. 

P7Leumo-2)ericardium,  or  air  in  the  pericardium,  is 
due  to  gas  arising  from  post-mortem  changes,  as  a  rule, 
and  is  rarely,  if  ever,  seen  during  life,  and  pneumo- 
hydro-pericardium,  if  such  a  thing  could  exist  during 
life,  would  give  the  same  physical  signs  as  pneumo- 
hydro-pericarditis,  already  described. 

Myocarditis. 

Myocarditis,  or  carditis,  signifies  inflammation  of  the 
heart  muscle  itself.     When  present  it  is  usually  associ- 


HYPERTROPHY  OF  THE  HEART.         245 

ated  with  endocarditis  or,  more  frequently,  with  peri- 
carditis. In  the  acute  form,  the  pain  in  the  cardiac 
region  is  extreme,  the  pulse  rapid  and  weak.  In  the 
chronic  fomi,  the  symptoms  are  those  of  a  weak  heart, 
with  want  of  correspondence  between  the  heart  and 
pulse  beat.     Neither  form  is  diagnosticated  during  life. 

Hypertrophy  of  the  Heart. 

Hypertrophy  of  the  heart  differs  from  hyperplasia. 
In  the  former  case  the  existing  anatomical  elements 
are  enlarged,  in  the  latter  their  number  is  increased 
(Flint).     In  both  cases  the  heart  is  enlarged. 

Hyi^ertrophy  may  be  general,  or  limited  to  one  or 
more  of  its  comj)artments.  In  the  latter  case  the  left 
ventricle  is  by  far  the  most  frequently  affected,  then 
the  left  auricle,  then  the  right  ventricle,  and  lastly  the 
right  auricle  may  sometimes  be  somewhat  enlarged. 
Again,  the  hypertroi^hy  may  be  concentric,  simple,  or 
eccentric.  In  the  first  case  the  walls  are  thickened  and 
the  cavities  become  smaller.  This  is  so  rare  that  it  is 
more  theoretical  than  practical,  and  may  be  thrown  out 
altogether.  Simple  enlargement  is  not  common  either 
- — that  is,  thickening  of  the  walls — the  cavities  remain- 
ing the  same.  Indeed,  hypertrophy  or  enlargement  of 
the  heart  from  any  cause  is  so  uniformly  of  the  eccen- 
tric ^'ariety,  that,  unless  otherwise  specified,  enlarge- 
ment of  the  heart  will  always  be  meant  to  be  eccentric 
hypertroi^hy — that  is,  hypertrophy  ^^dtll  dilatation, 
usually  termed  hyxDertrox^hous  dilatation,  or  dilated 
hypertrophy. 

Of  the  causes  of  enlargement  of  the  heart,  {l)valvu- 
lar  lesions,  as  previously  stated,  are  the  most  frequent. 


246  PHYSICAL   DIAGNOSIS. 

Moreover,  each  of  these  lesions  gives  rise  to  its  o^^^l 
characteristic  enlargement,  which  will  be  marked  in 
proportion  to  the  degree  of  the  lesions.  Thus,  mitral 
regurgitation  causes  enlargement  (dilated  hypertrophy) 
of  the  left  auricle,  left  ventricle,  and  right  ventricle  in 
the  order  named.  Mitral  obstruction  causes  enlarged 
left  auricle  and  right  ventricle.  Aortic  obstruction 
gives  rise  to  enlarged  left  ventricle  and  aortic  regurgi- 
tation also,  only  the  enlargement  is  usually  more 
marked  in  aortic  regurgitation ;  and  in  either  case,  but 
especially  in  aortic  regurgitation,  there  may  occur  rela- 
tive insufficiency  of  the  mitral  valves,  with  consequent 
enlargement  of  the  left  auricle,  if  not  the  right  ventri- 
cle, also,  in  time.  Pulmonary  (pulmonic)  obstruction 
or  regurgitation  will  lead  to  enlargement  of  the  right 
ventricle  as  would  also  tricuspid  regurgitation,  relative, 
or  resulting  from  foetal  endocarditis,  while  tricuspid 
obstruction  would  cause  enlargement  of  the  right  auri- 
cle only. 

(2)Br/r/7ifs  Disease  of  the  Kidneys. — In  the  chronic 
interstitial  variety  there  is  enlargement  of  the  left  ven- 
tricle only,  and  this  is  not  due  to  valvular  lesion  but 
simply  to  the  fact  that  the  left  ventricle  has  extra 
work  to  perform  in  overcoming  the  obstruction  due  to 
the  lessened  calibre  {lumen)  of  the  arterioles  through- 
out the  body.  In  the  chronic  tubular  variety  of 
Bright's  disease  of  the  kidneys,  there  is  liability  to  in- 
flammation of  serous  membranes  generally,  the  endo-. 
cardium  included,  with  resulting  valvular  lesion.  En- 
largement of  the  heart,  therefore,  in  chronic  tubular 
nephritis  is  usually'  due  to  valvular  lesion,  resulting 
from  an  endocarditis. 


lIYPEKTKOPnY   OF   THE   HEART.  247 

(3)  General  Vesicular  Empliyseina. — In  this  case 
there  is  enlargement  of  the  right  ventricle,  owing  to 
obstruction  to  the  pulmonary  circulation. 

(4)  ExopMlialTnic  goitre,  called  also  cardio-thyroid 
exophthalmos,  Basedow's,  or  Graves'  disease.  Here  we 
have  general  cardiac  enlargement  due  to  over  nourish- 
ment from  vaso-motor  dilatation  of  the  nutrient  vessels 
of  the  heart.  According  to  Niemeyer,  Bamberger,  and 
others,  the  nutrient  vessels  of  the  heart  in  this  disease 
are  enlarged  from  vaso-motor  dilatation  due  to  some 
disturbance  of  the  cervical  ganglia  of  the  sympathetic 
nervous  system  (see  Exophthalmic  Goitre). 

(5)  Palpitation  from  anemia,  or  other  cause,  may 
give  rise  to  enlargement  of  the  heart  from  its  overwork. 
Tlie  alcoholic  habit  probably  acts  somewhat  in  this 
way.  Habit,  mode  of  life,  occupation  requiring  pro- 
longed muscular  exertion,  as  among  athletes,  and  the 
like,  also  enlarge  the  heart  to  a  certain  extent,  as  well 
as  excessive  venery.  The  x^hysical  signs  of  hypertro- 
phy of  the  heart  with  dilatation  are  usually  more 
marked  than  they  are  when  simple  hypertrophy  alone 
exists.     They  are: 

Inspection. — The  enlargement  is  always  more  to  the 
patient's  left  than  right,  and  the  line  of  the  base  is 
rarely,  if  ever,  changed.  The  extent  of  the  visible  im- 
pulse is  increased,  and  there  is  more  or  less  prominence 
of  the  prsecordial  region.  The  apex-beat  is  also  seen 
to  be  more  forcible  than  normal,  and  it  may  be  as  low 
as  the  ninth  rib  and  outside  the  mammillary  line.  En- 
largement of  the  right  ventricle  pushes  the  apex  fur- 
ther to  the  left  than  normal,  but  the  apex  is  also  low- 
ered Avhen  the  left  ventricle  is  enlarged. 


248  PHYSICAL   DIAGNOSIS. 

Palpation. — The  impulse  is  heaving  and  lifting  in 
character,  with  or  without  thrill,  and  its  area  is  in- 
creased. Hypertroi)hy  of  the  right  ventricle  usually 
gives  a  strong  epigastric  impulse.  ^\Tien  the  left  ven- 
tricle is  hypertrophied  the  apex-beat  is  carried  down 
and  out.  Prjesystolic  impulse  is  sometimes  felt  over 
an  hypertrophied  left  auricle,  as  may  occur  in  mitral 
disease. 

The  radial  pulse  in  hypertrophy  of  the  right  side  of 
the  heart  is  not  appreciably  affected  in  character.  But 
in  hjqDertrophy  of  the  left  ventricle  without  regurgita- 
tion or  obstruction,  the  radial  pulse  is  full,  prolonged, 
and  sustained. 

Percussion. — Both  areas  of  dullness  are  increased, 
laterally  and  vertically.  General  enlargement  may 
give  dullness  on  percussion  from  the  third  to  the  eighth 
rib,  and  from  an  inch  to  the  right  of  the  sternum  to 
two  or  three  inches  outside  the  left  nipple.  Walshe 
mentions  a  case  where  enlargement  (dilated  hypertro- 
phy) of  the  heart  was  so  extensive  as  to  be  mistaken 
for  pleurisy  of  the  left  side  with  effusion.  Hypertro- 
phy of  the  left  ventricle  gives  dullness  usually  beyond 
the  left  nipple ;  of  the  right  ventricle,  considerably  to 
the  right  of  the  sternum.  In  hjqDertrophy  of  the  left 
auricle  the  area  of  dullness  over  that  portion  is  en- 
larged and  more  marked. 

Auscultation . — The  first  sound,  dull,  muffled,  pi'o- 
longed,  diffused  over  a  larger  area  than  in  health,  and 
increased  in  intensity,  may  indeed  so  closely  resemble 
a  slight  systolic  murmur  as  to  make  it  sometimes  diffi- 
cult to  decide;  and  the  second  sound  is  also  louder 
and  more  diffused  than  in  health.     If  munnurs  are 


DILATATIOX    OF    THE   IIKAKT.  249 

present  they  will  more  or  less  obscure,  or  take  tlie 
place  of  the  heart  sounds.  There  is  diminution  or 
absence  of  the  respiratory  murmur  over  the  precordial 
space. 

Hypertrophy  of  the  right  auricle  rarely  occurs,  and 
then  it  is  due  to  tricusj)id  regurgitation  usually,  as 
tricusi3id  obstruction  (stenosis,  constriction)  is  almost 
"unknown  during  life  (AValshe). 

Dilatation  of  the  Heart. 

Dilatation  of  the  heart  may  be  one  of  three  kinds : 

(1)  hyiDertrophous  dilatation,  or  dilated  hypertrophy, 
which  is  the  most  common  form,  and  just  considered ; 

(2)  sim]ple  dilatation,  where  the  walls  remain  the  same 
but  the  cavities  are  enlarged ;  and  (3)  attenuated  dila- 
tation (Walshe),  where  the  cavities  are  not  only  en- 
larged, but  the  walls  are  thinner  than  normal.  It  is 
the  last  variety  that  requires  our  attention.  Attenu- 
ated dilatation,  or  dilatation  witJioiit  compensating 
Jiyperti'opliy,  is  a  hopeless  disease.  It  may  result  from 
valvular  lesion,  or  general  vesicular  emphysema,  where 
dilatation  and  hypertrophy  of  certain  parts  occur  to- 
gether, ]producing  the  various  enlargements  character- 
istic of  those  diseases,  as  already  fully  described. 
Presently  the  time  arrives,  however,  when  hypertroj)hy 
ceases  to  compensate,  and  then  the  case  becomes  one  of 
dilatation,  since,  evidently,  enlargement  cannot  con- 
tinue to  go  on  indefinitely.  In  other  cases  dilatation 
occurs  from  inherent  weakness  of  the  heart  niuscle 
itself,  in  other  words,  from  no  known  cause.  Thoracic 
aneurism  causes  dilatation  in  so  far  as  it  is  a  cause  of 
■obstruction  to  the  outflow  of  blood,  and  in  this  way 


250  PHYSICAL    DIAGNOSIS. 

acts  as  valvular  lesion  would.  But  the  underlying 
cause  of  aneurism,  if  it  be  gout,  syphilis,  or  lead  i^ois- 
oning,  may  cause  weakness  of  the  heart  muscle  also, 
and  thus  favor  dilatation.  The  physical  signs  of  car- 
diac dilatation  are: 

I}iS2:)ectlon.—T\ie  visible  area  of  the  apex-beat,  if  in- 
deed it  be  visible,  is  increased  without  any  particular 
point  of  maximum  intensity.  Dyspnoea  and  cyanosis 
are  sometimes  observed,  especially  after  attempted  ex- 
ertion. 

Palpation. — Tlie  cardiac  impulse  is  feeble,  its  area  is 
increased,  rarely  is  there  any  thrill,  but  rather  an  un- 
dulating motion  over  the  prsecordial  region,  especially 
if  there  be  mitral  regurgitation.  The  radial  pulse  is 
feeble,  sometimes  irregular,  small,  and  compressible. 

Percussion. — The  area  of  cardiac  dullness  is  in- 
creased in  the  direction  of  the  part  dilated,  or  generally 
increased  if  the  dilatation  affect  the  whole  heart.  In 
the  latter  case  it  is  oval  or  somewliat  square  in  shape, 
instead  of  being  triangular,  M^th  the  base  dowuAvard, 
as  in  pericarditis  with  effusion. 

A  liscultatlon. — Both  sounds  are  short,  abrupt,  feeble, 
and  equal  in  duration,  the  second  being  often  inaudi- 
ble at  the  apex.  The  post-systolic  or  first  period  of 
silence  is  prolonged.  Endocardial  murmurs,  when 
present,  are  indistinct.  The  respiratory  murmur  is 
diminished  or  absent  over  the  precordial  region,  owing 
to  the  cardiac  enlai'gement. 

Fatty  DK(n<:xKKATioN^  of  the  Heart. 

Fatty  heart  is  of  two  kinds,  (1)  tliat  in  which  the  fat 
is  added  to  the  organ  without  or  within,  or  between  its 


FATTY   DEGT<mERATIO]Sr    OF   THK    HKAUT.  2^1 

fibres,  and  causing  trouble  by  ju'essure;  and  (2)  that  in 
which  the  muscular  fibre  is  replaced  by  fatty  tissue. 
The  first  is  by  Walshe  termed  fatty  infiltration ;  and 
is  simply  an  accumulation  of  fat.  The  second  is  known 
as  Quain's  fatty  degeneration,  and  by  Walshe  is  termed 
fatty  metamorxAosis  of  the  heart.  The  first  variety 
may  give  some  inconvenience,  but  may  be  modified,  if 
not  entirely  got  rid  of,  by  a  Carlsbad  course,  or  re- 
stricted diet,  if  thought  necessary.  The  second  is  a 
serious  and  often  fatal  disease.  There  is  no  knowTi 
cause  for  Quain's  fatty  heart.  Obesity,  though  associ- 
ated with  fatty  infiltration,  bears  no  relation  whatever 
to  fatty  metamorphosis.  Cardiac  fatty  metamorphosis 
occurs  at  middle  life,  or  x^ast,  and  in  men  rather  than 
women.  It  also  occurs  more  frequently  among  the 
upper  classes  than  among  laborers.  It  is  x^robable  that 
any  condition  that  interferes  with  the  x^rox^er  nutrition 
of  the  heart,  such  as  sclerosis  of  its  nutrient  vessels 
from  various  causes,  and  leading  to  cardiac  ischsemia 
(see  Angina  Pectoris),  may  predisx)ose  to  fatty  metamor- 
phosis. But  in  tuberculous  and  other  wasting  diseases 
the  heart  is  more  frequently  normal  than  fatty,  and 
hence  they  cannot  be  said  to  be  causes  of  the  disease. 
The  real  cause,  whatever  it  riiay  be,  is  x^robably  inherited 
rather  than  acquired.  The  jjliysical  signs  of  fatty  met- 
amorxDhosis  of  the  heart  (Quain's)  are  as  follows : 

Inspection. — The  heart's  imx^ulse  is  usually  not  ob- 
servable, owing  to  its  feebleness.  The  patient  may  be 
observed  to  be  suffering  with  a  fit  of  dyspnoea  and 
having  a  x^eciiliarly  anxious  expression.  The  arc  us 
senilis  may  be  present,  but  ax^pears  to  bear  no  fixed 
relation  to  the  disease. 


252  PHYSICAL    DIAGNOSIS. 

« 

Palpation. — The  imi)ulse  is  so  weak  as  to  be  scarcely 
felt,  even  tliough  the  patient  be  emaciated  and  leans 
forward.  If  the  heart  was  hypertrophied  first,  there 
may  be  an  undulating  impulse,  as  in  attenuated  dilata- 
tion. The  pulse  is  feeble  and  sometimes  abnormally 
slow ;  or  it  may  be  irregular  and  intermitting,  chang- 
ing from  abnormal  slowness  to  raiDidity — from  20  to  30 
beats  per  minute  to  150,  but  always  weak. 

Percussion. — The  area  of  dullness  will  be  normal, 
unless  hypertrophy  co-exists,  when  it  would  be  larger, 
or  smaller  if  there  be  atrophy. 

Auscultation. — The  first  sound  of  the  heart,  even  at 
the  apex,  instead  of  being  somewhat  low  jjitched  and 
of  well-marked  duration,  as  in  health,  now  becomes 
short,  high  pitched,  and  weak,  and  the  first  rest  is  not- 
ably prolonged.  The  second  sound  is  feeble  but  dis- 
tinct, and  is  accentuated  in  the  aortic  or  pulmonary 
intersjjace,  according  as  the  right  or  left  ventricle  is 
chiefly  affected.  Of  course,  murmurs  of  various  kinds 
may  be  i)resent,  but  they  are  rare,  and  when  they  are 
present  they  are  usually  weak.  The  i^atient  feels  bet- 
ter, according  to  the  late  Dr.  Alonzo  Clark,  lying  down 
with  the  head  low,  as  the  heart  would  then  have  less 
to  do. 

Atrophy  of  the  Heart. 

Atrophy  of  the  whole  heart,  unless  it  be  senile,  is  of 
rare  occurrence.  It  sometimes  takes  place  in  connec- 
tion with  wasting  diseases  like  phthisis,  suppurating 
bonp,  calcification  of  the  coi'onary  arteries,  tightly  ad- 
herent ])ericar(lium,  and,  rarely,  after  pregnancy.  Local 
atrophy  of  some  part  of  the  heart  is  more  common,  and 


CARDIAC  DIIOPSY — EXOPJITIIALMIO    GOITKJ:.       253 

occurs  in  connection  with  fatty  heart.  In  mitral  de- 
struction, also,  the  left  ventricle  is  somewhat  atrophied, 
and  when  this  lesion  occurs  in  childi'en,  there  tippears 
to  be  usually  more  or  less  deformity  of  the  chest,  re- 
sembling the  so-called  pigeon  breast.  The  flattening 
is  particularly  well  marked  in  the  lower  precordial 
region  to  the  left  of  the  sternum,  but  whether  it  be 
due  to  atrophy  of  the  left  ventricle,  or  a  lack  of  gen- 
eral nutrition  from  imperfect  cardiac  function,  is  not 
exactly  known.  In  case  of  general  atrophy,  the  area 
of  percussion  dullness  is  diminished,  the  heart's  sounds 
are  clear,  the  impulse  is  feeble,  the  pulse  quick  and 
feeble,  but  regular,  and  there  is  a  great  tendency  to 
palpitation  (Da  Costa). 

Caediac  Dropsy. 

Cardiac  dropsy  usually  begins  about  the  feet  and 
ankles,  and,  gTadually  extending  upward,  is  afterward 
met  with  in  various  localities.  It  is  most  constantly 
associated  with  dilatation  of  the  right  heart,  as  in  tri- 
cuspid regurgitation,  but  there  are  exceptions.  Albu- 
men, when  present  in  the  urine,  is  due  to  renal  conges- 
tion simply,  unless  there  be  also  co-existing  structural 
lesion  of  the  kidneys. 

Exophthalmic  Goitre. 

Exophthalmic  goitre  (cardio-thyroid  exophthalmos, 
Basedow's  disease.  Grave's  disease),  in  order  to  be  com- 
plete, consists  of  three  factors :  (1)  palpitation  and  en- 
largement of  the  heart,  (2)  enlargement  of  the  thyroid 
gland,  with  throbbing  of  the  arteries  about  the  neck, 
and  (3)  protrusion  of  the  eyeballs.     The  disease  is  said 


254  PHYSICAL   DIAGNOSIS. 

to  be  due  to  some  change  in,  or  pressure  on,  the  cervi- 
cal ganglia  of  the  sympathetic  system  of  nerves,  which 
send  branches  directly,  or  indirectly,  to  the  three  local- 
ities mentioned. 

The  disease  is  usually  classed  among  the  neuroses,  or 
functional  disturbances,  of  the  heart,  but  inasmuch  as 
it  leads  to  cardiac  hypertroi)hy,  I  have  thought  it  best 
to  place  it  among  the  organic  diseases  of  the  heart.  It 
occurs  more  frequently  among  women  than  men,  and 
in  most  cases  the  women  are  usually  nervous,  if  not 
hysterical,  and  ansemic.  Sometimes  it  occurs  in  men, 
and  Graefe  mentions  the  case  of  a  young  man  in  whom 
it  Avas  suddenly  developed  on  account  of  nervousness 
at  the  prospect  of  being  married.  (!)  In  most  cases  it 
develojDS  slowly,  but  in  some  instances  (as  in  the  case  of 
the  young  man  just  cited)  it  may  develop  very  sud- 
denly. 

(1)  Palpitation  of  the  heart  usually  first  attracts  the 
attention  of  the  patient.  The  heart  is  observed  to  beat 
120  or  even  140  times  to  the  minute,  instead  of  60  to 
70.  Enlargement  of  the  heart  follows,  partly  from 
palpitation,  but  chiefly  from  overnutrition  of  the  organ. 
The  nutrient  vessels  of  the  heart  become  dilated  from 
vaso-motor  disturbances,  and  the  heart  receives  more 
blood  supply  than  normal.  Hence  its  palpitation  as 
well  as  OA'ergrowth. 

(2)  The  thyroid  gland  now  begins  to  enlarge,  and 
throbbing  of  the  inferior  thyroid,  carotid,  and,  some- 
times, temporal  arteries  is  observed. 

The  enlargement  of  the  thyroid  gland  may  not  be 
very  percei)tible,  and  when  present,  is  due  to  dilatation 
of  its  vessels,  serous  infiltration,  and  hyjjerplasia  of  its 


EXOPHTHALMIC   GOITUE 


255 


tissues.  The  gland  is  rarely  so  mLich  enlarged  as  in 
simple  goitre  (cretinism,  Derbyshire  neck),  where  it 
ma 3^  be  enormously  hypertroj^hied  or  increased  in  size 
by  fibrous  or  calcareous  deposits. 

Cretinism   (with  goitre),   so-called  from  deformity 


Fig.  30.— Exophthalmic  Goitre.    (After  Eichorst.) 

or  mutilation,  supposed  to  result  from  intermarriage, 
is  a  local  disease,  and  found  not  only  among  those 
who  intermarry,  but  also  among  young  girls  and  women 
who  carry  heavy  burdens  and  are  habitually  subjected 
to  bad  hygienic  conditions,  as  in  certain  parts  of  the 
old  world.  For  these  reasons  it  is  thought  that  the 
thyroid  gland  becomes  enlarged,  as  in  foetal  life,  be- 


256  PHYSICAL    DIAGNOSIS. 

cause  the  lungs  are  not  equal  to  the  task  put  upon 
them  of  aerating  the  blood,  and  not  because  of  any 
particular  lack  of  iodine  in  the  water,  which  is  the 
same  as  it  was  in  those  localities. a  thousand  years 
ago.  Hence  cretinism  (with  goitre)  is  becoming  less, 
thanks  to  the  steam-engine ,  which  enables  people  to 
leave  home  and  marry  elsewhere,  and  other  advances 
made  by  Christian  civilization,  and  not  because  of  any 
change  in  the  drinking  water  of  certain  localities.  To 
return  to  exophthalmic  goitre,  which  disease  is  not 
confined  to  any  locality,  but  which  may,  and  does, 
occur  in  all  parts  of  the  •\vorld.  We  have  seen  why 
the  heart  and  thyroid  gland  are  enlarged — on  account 
of  the  vaso-motor  dilatation  of  their  blood-vessels. 
The  arteries  about  the  neck  and  temples  sometimes 
throb  because  they  become  dilated,  and  the  blood  is 
sent  through  them  with  great  force  by  the  hypertro- 
phied  heart.  (3)  Lastly,  the  eyes  in  this  disease  pro- 
trude, because  of  the  increase  of  the  fat  at  the  bottom 
of  the  orbit.  The  intra-orbital  fat  is  increased  from 
hyperplasia,  and,  according  to  Niemeyer,  it  may  be- 
come not  only  hyperjjemic,  but  also  opdematous.  Some- 
times the  eyes  protrude  so  that  the  lids  cannot  be 
closed,  and  consequently  ulceration  of  the  cornea,  from 
foreign  particles,  may  result.  The  upper  lid,  according 
to  Graefe,  becomes  fixed  early  in  the  disease,  from 
sx)asm  of  the  levator  muscle,  and  consequently  does  not 
follow  the  eye  in  looking  downward. 

All  three  factors  of  this  disease  are  not  equally  pres- 
ent in  every  case.  The  heart  may  be  chiefly  aifected, 
with  scarcely  perceptible  change  in  the  thyroid  gland, 
^^  hile  the  eyes  remain  perfectly  nonnal,  and  so  on.     In 


ANGINA    PECTORIS.  257 

course  of  time,  however,  all  the  j)lienomena  are  apt  to 
apj)eai'.  Anemia  is  observable  in  most  cases  before 
treatment,  and  marked  venous  hum,  with  or  without 
thrill,  in  the  neck  is  pretty  constant.  Not  infrequently 
a  true  anaemic  (hsemic)  murmur  is  heard  with  systole 
over  the  pulmonary  interspace ;  and  over  the  aortic  in- 
terspace a  loud,  systolic,  dynamic  murmur,  owing  to 
the  force,  I  presume,  with  which  the  arterial  blood  is 
forced  at  times  through  the  aortic  orifice  by  the  hyper- 
troi)hied  left  ventricle ;  but,  unlike  the  anaemic  murmur 
over  the  pulmonic  (pulmonary)  intersx)ace,  it  is  incon- 
stant, like  all  other  dynamic  murmurs.  The  physical 
signs  of  cardiac  hypertrophy  have  already  been  con- 
sidered (p.  247).  Unless  the  patient  dies  from  apoplexy 
or  rarely,  suffocation  due  to  pressure  on  the  trachea, 
the  prognosis  is  not  bad.  Recovery,  according  to  Me- 
meyer,  is  more  common  in  this  disease  than  death. 

Angina  Pectoris. 

Angina  pectoris,  or  suffocative  breast-pang,  is  usually 
defined  to  be  a  paroxysmal  neurosis  of  the  heart,  and 
always  attended  with  pain,  whatever  other  symptoms 
may  be  present.  As  it  is  usually  accompanied  or  pre- 
ceded by  organic  changes  in  the  heart,  I  have  thought 
it  best  to  place  it  among  the  organic,  rather  than  func- 
tional, diseases  of  that  organ. 

The  disease  is  of  two  kinds,  true  and  false.  The 
latter  is  almost  wholly  confined  to  young  hysterical 
women.  In  these  cases  the  pain  does  not  extend 
through  to  the  back  and  up  to  the  neck  and  down  the 

left  arm,  but  is  simply  located  apparently  in  the  chest 
17 


258  PHYSICAL    DIAGNOSIS. 

wall,  like  an  intercostal  neuralgia,  but  attended  with 
palpitation  of  the  heart  and  d3^si3noea. 

True  angina  pectoris,  on  the  other  hand,  attacks  men 
usually,  and  those  in  the  upper  walks  of  life,  either  at 
middle  age  or  past.  It  depends  upon  what  is  termed 
ischemia  of  the  myocardium,  which  is  simply  a  local 
anaemia  of  the  heart,  due  to  periarteritis  or  sclerosis 
of  its  nutrient  vessels,  the  latter  resulting  from  en- 
darteritis, and  often  terminating  in  ossification.  Pain 
is  not  always  present  in  all  cases  of  cardiac  arterial 
sclerosis,  for  this  condition  gives  rise  to  different  varie- 
ties of  symptoms,  as  we  shall  see;  but  when  pain  is 
present,  it  is  analogous  to  the  pain  observed  in  senile 
gangrene  due  to  arterial  obstruction.  The  causes  of 
localized  anaemia  or  ischaemia  of  the  heart  are  those 
Mdiich  produce  sclerosis  of  its  nutrient  vessels.  These 
are,  according  to  Huchard,  of  Paris,  (1)  toxic,  as  alco- 
hol, tobacco,  especially  cigarette  smoking,  malaria,  and 
lead,  (2)  diathetic,  as  gout,  rheumatism,  and  syphilis, 
and  (3)  physical,  moral,  and  intellectual  oveipressure. 

Obliterating  arteritis  of  the  small  coronary  vessels 
of  the  heart  is  the  lesion  commonly  found,  and  if  this 
arteritis  be  slow,  time  for  comjDensating  hypertrophy 
may  be  allowed.  But  if  the  arteritis  is  rapid  in  its 
progress,  dilatation  from  weakness  of  the  heart's  walls, 
or  fatty  degeneration,  results.  Tobacco,  it  would  ap- 
peal-, is  more  destructive  to  the  heart  than  alcohol. 

Cardiac  arterial  sclerosis  gives  rise  to  five  different 
forms  of  symptoms:  (1)  the  pulmonary  form  with 
symptoms  of  cardiac  asthma,  so-called  (see  Asthma); 
(2)  the  i)ainful  form  of  true  angina  pectoris;  (3)  the 
tachycardiac  foi-m,  in  which  there  is  simply  rapidity 


ANGINA    PJajTOltlS.  259 

and  weakness  of  the  heart's  action;  (4)  the  arythmic 
fomi,  in  which  the  rhythm  becomes  irregular,  as  often 
occurs  from  the  use  of  tobacco  and  on  account  of  dys- 
pepsia ;  and  (5)  the  asystolic  form,  in  which  TnjAd  dila- 
tation  occurs,  due  to  weakening  of  the  walls  of  the 
heart  from  the  nutrient  arterial  sclerosis.  Of  these  five 
forms  of  manifestations  of  cardiac  arterial  sclerosis, 
and  consequent  ischfemia  of  the  heart,  only  one,  the 
painful  form,  or  angina  pectoris  proper,  will  be  consid- 
ered here.  A  patient,  however,  who  has  this  disease 
manifested  in  one  form,  may  have  a  return  of  it  in  any 
of  the  other  four  forms,  for  the  same  form  does  not 
necessarily  return  every  time,  when  once  commenced. 

Angina  pectoris  usually  comes  on  without  warning. 
The  patient  may  be  asleep  in  bed,  or  it  may  be  after  a 
heavy  meal,  or  during  a  fit  of  anger,  or  Avhile  walking 
briskly,  especially  wp  hill,  against  a  stiff  breeze.  Sud- 
denly a  pain,  like  a  death  pang,  joierces  him  through 
and  through  in  the  lower  praecordial  region.  It  not 
only  extends  through  to  the  back,  but  up  to  the  neck 
and  down  the  left  arm,  usually,  but  sometimes  both 
arms,  and  even  one  or  both  of  the  lower  extremities. 
This  fearful  neuralgic  pain  is  thought  to  originate  in 
the  cardiac  plexus  of  nerves,  and  extends  not  only  to 
the  parts  mentioned,  but  along  the  gastric  branches  of 
the  j)neumogastric  nerve,  as  evidenced  by  the  belching 
of  wind  and  sometimes  even  vomiting.  The  pulmo- 
nary branches  of  the  pneumogastric  nerve,  on  the  other 
hand,  seem  to  escape  in  this  painful  form,  since  the 
patient  not  only  can  breathe  freely,  but  sometimes  a 
deep  breath  will  give  speedy  relief.  The  attack  may 
last  from  a  few  seconds  or  minutes  to  an  hour  or  more, 


260  PHYSICAL    DIAGiS^OSIS. 

if  the  patient  lives,  a^d  may  consist  of  one  prolonged 
attack  or  many  separate  and  distinct  attacks.  In  tlie 
latter  case  it  may  last  several  days  or  more.  During 
the  attack  the  pulse  may  not  be  notably  affected,  but 
if  the  attack  be  prolonged  the  pulse  becomes  more  fre- 
quent and  feeble,  and  the  patient  may  die  of  sheer  ex- 
haustion, or  else  suddenly  from  paralysis,  and  not 
spasm,  of  the  heart.  In  either  case  it  is  a  most  cruel 
death. 

A  patient  who  has  had  angina  pectoris  will  surely 
have  a  return  of  it  in  time,  unless  the  case  be  not  far 
advanced,  and  the  utmost  care  is  observed.  Death  may 
occur  in  the  first  attack,  or  in  any  of  those  succeeding. 
It  is  absolutely  uncertain.  Arnold,  of  Eugby,  died 
with  it,  as  did  the  great  John  Hunter. 

In  a  lesser  degree  than  just  described,  a  patient  may 
only  have  attacks  of  irregular  rhythm  (arythmic)  or 
rai)id  pulse  (tachycardia),  vdth  pain  in  the  left  arm. 
This  pain  may  extend  down  the  whole  arm,  or  be  con- 
fined to  the  left  wrist  only,  or  be  indefinitely  situated 
somewhere  in  the  left  breast.  Or  it  may  change  from 
one  of  these  localities  to  the  other,  now  in  the  left  arm, 
now  only  at  the  wTist,  or  even  in  one  or  more  fingers  of 
the  left  hand,  now  in  the  left  shoulder. 

Diseases  of  the  Heaut  that  cause  Sudden 
Death. 

Sudden  death  from  heart  disease  is  not  so  common 
as  the  laity  generally  suppose.  There  are  certain  foi-ms 
of  disease  of  the  heart,  however,  which  do  undoubtedly 
cause  sudden  death,  while  other  forms,  thongli  fatal 
from  the  first,  give  rise  to  complications  which  produce 


IIEAKT  DISEASES  CAUSING  SITDDEN  DEATH.         201 

death  indirectly  rather  than  directly  through  the  heart 
itself. 

(1)  Aortic  RegnrgUatlon. — ISTot  only  may  sudden 
death  from  cerebral  a230i)lexy  occur  in  this  disease^ 
due  to  the  force  with  which  the  blood  is  driven  from 
the  left  ventricle,  owing  to  the  existing  dilated  hyj)er- 
trophy  of  that  part  of  the  heart,  but  it  may  also  occur 
in  some  way  not  yet  thoroughly  understood,  but 
thought  by  some  to  be  due  to  failure  of  the  circulation 
in  the  nutrient  vessels  of  the  heart.  It  is  claimed  by 
some  that,  owing  to  the  enormous  enlargement  of  the 
left  ventricle,  which  sometimes  occurs  in  this  disease, 
the  coronary  arteries  are  so  pressed  upon  that  blood 
cannot  enter  them,  and  the  heart  fails  from  want  of 
blood  supply.  A  case  in  ]Doint  was  that  of  a  man  of 
excellent  habits,  aged  thirty-five,  and  otherwise  in  ap- 
parently good  health.  He  was  seen  by  Dr.  Francis 
Delafield,  of  this  city,  at  my  request,  and  the  diagno- 
sis confirmed.  He  died  suddenly  on  his  stairway, 
without  cerebral  lesion, 

(2)  Angina  Pectoris. — In  this  disease,  as  just  de- 
scribed, the  patient  may  die  suddenly,  not  from  spasm, 
but  from  paralysis  of  the  heart,  from  failure  of  the  cor- 
onary circulation,  due  to  cardiac  arterial  sclerosis,  and 
shock  from  the  terrific  pain. 

(3)  Fatty  Degeneration.,  or  Meiamorpliosis  {Quain's). 
— This  also  may  lead  to  sudden  death  from  sudden 
failure  of  the  heart  to  act,  or  from  rupture. 

(4)  Extreme  Dilatation. — In  this  disease,  also,  the 
heart  may  suddenly  fail  or  rupture.  Dropsy  and  other 
complications,  however,  may  and  are  likely  to  cause 
death  before  such  a  sudden  catastrophe. 


262  PHYSICAL    DIAGNOSIS. 

(5)  Aneurism  of  the  Heart. — Usually  situated  in  the 
wall  of  tlie  left  ventricle  near  the  apex,  and  almost 
impossible  to  distinguish  between  it  and  mitral  regur- 
gitation. Both  are  accompanied  with  an  apex  systolic 
murmur,  and  both  cause  enlargement  of  the  left  ventri- 
cle. But  in  mitral  regurgitation  the  murmur  is  usu- 
ally louder  than  in  cardiac  aneurism,  and  more  fre- 
quently heard  posteriorly,  besides  the  accompanying 
enlargement  of  the  right  ventricle,  with  accentuation  of 
the  second  sound  over  the  pulmonary  interspace,  which 
are  also  usually  observed  in  mitral  regurgitation  but 
not  in  cardiac  aneurism.  Sudden  death  in  the  latter 
disease  is  generally  due  to  rupture  of  the  heart. 

(6)  Fibrosis  of  the  heart,  as  sometimes  results  from 
syphilis,  alcoholism,  gout,  rheumatism,  and  lead  poi- 
soning. The  muscular  tissue  becomes  more  and  more 
replaced  by  connective  tissue,  instead  of  fat,  as  in  fatty 
degeneration,  until  finally  it  fails  to  act. 

(7)  BrigJWs  Disease. — Lastly,  in  chronic  interstitial 
nei)hritis,  the  left  ventricle  becomes  enlarged,  chiefly 
hypertrophied,  while  the  arterioles  are  fibrosed  and 
brittle.  Hence  cerebral  apoplexy  and  sudden  death 
not  unf  requently  occur  in  this  disease.  In  many  cases, 
it  is  preceded  by  retinal  apoplexy,  plainly  to  be  ob- 
served with  the  ophthalmoscope,  as  in  a  typical  case  in 
which  I  called  Dr.  David  AVebster,  of  this  city,  in  con- 
sultation about  a  year  ago. 

Mitral  regurgitation  and  obstruction  are  both  almost 
necessarily  fatal  diseases  when  they  occur  early  in  life. 
They  both  lead  to  constant  pulmonary  congestion,  with 
sequential  dilated  hypertrophy  of  the  right  ventricle 
and  consequent  hemorrhagic  pulmonary  infarction,  or 


FUJN^CTIO.VAL    DISEASES    OF    I'lfK    TrKART.  20H 

cardiac  dropsy,  or  both,  as  has  been  already  descj-ibed. 
The  liver,  spleen,  kidneys,  and  gastro-intestinal  tract 
are  subject  to  repeated,  if  not  chronic,  congestion,  with 
all  the  train  of  evils  belonging  to  such  a  condition. 

FrjNCTioisrAL  Diseases  of  the  Heakt. 

Palpitation,  irregular  rhythm,  pain  and  syncojDe  or 
fainting,  are  the  chief  so-called  functional  diseases  of 
the  heart.  Littls  need  be  said  about  fainting  and  neu- 
ralgia as  functional  cardiac  diseases,  since  they  are 
found  among  the  nervous  and  hysterical — chiefly  anae- 
mic or  spoilt  and  over-petted  young  women.  Among 
the  aged,  or  those  having  weak  heart  due  to  organic 
change,  syncope  has  more  significance.  In  any  case, 
the  patient  lies  down  or  falls,  either  one  of  Avhicli  usu- 
ally causes  reaction,  as  the  heart  has  less  to  do  with 
the  body  in  the  recumbent  position.  In  those  cases  of 
neuralgia  of  the  heart  occurring  in  men  of  middle  life 
or  past,  if  the  pain  extend  to  the  left  arm  and  be  ac- 
companied by  palpitation  or  irregular  rhythm,  it  usu- 
ally indicates  cardiac  arterial  sclerosis,  as  already 
described. 

Palpitation. — All  authors  nearly  agree  that  by  pal- 
pitation of  the  heart  is  meant  increased  force  of  the 
heart's  action  as  well  as  increased  frequency.  Flint, 
however,  says  that  sometimes  the  heart's  action  may 
be  feeble.  Walshe  describes  three  kinds  of  i^alpita- 
tion:  (1)  simple  palj^itation,  where  the  heart's  force  is 
increased  but  the  rhythm  is  regular  and  there  is  no 
increase  of  frequency;  (2)  irregularity  in  force  and 
rhythm,  occurring  in  paroxysms;  and  (3)  increased 
frequency,  with  diminution  of  force.     The  second  vari- 


264  PHYSICAL    DIAGNOSIS. 

ety  is  the  one  usually  referred  to  when  speaking  of 
palpitation. 

Of  course  palpitation  of  any  kind  may  be  eoincident 
v,'ith,  or  due  to,  organic  disease  of  the  heart.  But  it 
may  occur  also  in  a  perfectly  normal  heart,  as  proven 
by  the  normal  size  of  the  organ,  which  may  be  verified 
by  the  various  methods  of  physical  examination  alread}' 
described,  the  normal  heart  sounds,  and  the  absence  of 
adventitious  sounds  or  munnurs.  The  causes  of  func- 
tional cardiac  palpitation  and  irregular  rhythm  are  so 
nearly  allied  that  in  stating  one  we  state  both. 

Irregidar  Rhytlim. — This  usually  occurs  with  irreg- 
ular force  also,  and  may  be  only  momentary  or  last 
for  several  days  or  more.  There  is  every  conceivable 
kind  of  irregular  rhythm,  the  enumeration  of  which,  as 
a  learned  author  remarks,  would  allay  curiosity  rather 
than  prove  useful.  Sometimes  the  heart  intermits, 
with,  of  course,  corresponding  intermission  in  the 
radial  pulse.  Sometimes  the  radial  pulse  intermits 
when  the  heart  does  not.  This  may  occur  in  two  ways. 
If  the  heart  is  beating  frequently  and  feebly,  the  i)ulse 
wave  may  not  reach  the  wrist  every  time,  though  the 
heart  does  not  intermit.  This  is  termed  false  intermis- 
sion. Again,  while  the  left  ventricle  contracts  once, 
the  right  ventricle  may  beat  twice,  giving  two  systolic 
cardiac  shocks,  with  only  one  radial  pulse.  This  is 
termed  bigemmeny.  These  terms  could  be  multiplied, 
])ut  are  of  no  practical  use. 

Etiology. — Irregular  rhythm,  including  intermission 
of  the  heart,  may,  like  i)ali)itation,  be  associated  with, 
or  even  due  to,  organic  cardiac  disease.  More  fre- 
quently, however,  they  are  both   functional.     There 


FUlSrCTIONAL   DISEASES    f>F   TIIK    HKAK'I'.  205 

appears  to  be  no  valvular  lesion,  in  spite  of  the  state- 
ment of  authors,  that  is  characterized  by  any  particular 
palpitation  or  irregular  rhythm.  Cardiac  arterial  scle- 
rosis, fatty  metamorphosis  (Quain's),  fibrosis,  and  aneu- 
rism of  the  heart,  on  the  other  hand,  are  productive  of 
paroxysms  of  pal^^itation  and  irregular  rhythm  of  every 
known  kind.  They  are  to  be  known  by  the  physical 
and  other  signs  of  those  diseases  already  described — 
never  losing  sight  of  the  pain  in  the  left  arm.  The 
causes  of  functional  palpitation  and  irregular  rhythm 
may  be  stated  to  be  very  much  as  Walshe  has  said. 

(1)  Centric. — Chorea,  epilepsy,  hysteria,  and  cerebral 
and  spinal  irritation  from  any  causes,  especially  cerebral 
irritation  attended  by  insomnia,  as  from  over  study. 
The  boy  pianist,  Joseph  Hoffmann,  recently  was  pre- 
vented from  giving  concerts  in  this  city  at  the  instance 
of  the  Society  for  the  Prevention  of  Cruelty  to  Child- 
ren, one  of  the  signs  of  his  overwork  being,  as  was 
testified  to  by  one  of  his  attending  physicians,  inter- 
mittent pulse,  which  j)roved  to  be  due  to  cerebral  as 
well  as  spinal  irritation  from  overwork,  both  mental 
and  bodily. 

(2)  Rejiex,  or  Eccentric  Causes. — They  include  dys- 
pepsia in  all  its  forms;  intestinal  irritation  from 
worms  or  any  other  cause;  articles  of  diet,  as  coffee, 
tea,  and  alcohol  with  many  peoi)le;  genito-urinary 
irritation,  as  seen  in  cases  of  gonorrhoea,  cystitis,  uter- 
ine catarrh,  old  stricture,  ovarian  diseases,  and  sach 
like,  including  piles,  fissure  of  the  rectum,  rectitis  and 
proctitis. 

(3)  Blood  Poisoning  and  Ancemia. — Tobacco  un- 
doubtedly plays  a  very  important  part  in  the  produc- 


266  PHYSICAL    DIAGNOSIS. 

tion  of  heart  diseases,  both  functional  and  organic. 
ExcejDt  it  be  cocaine,  there  is,  j)ei'haps,  no  more  j)erni- 
cioiis  habit  than  the  tobacco  habit,  especially,  it  is 
said,  the  smoking  of  cigarettes,  ^ot  all  is  positively 
known  about  the  baneful  effect  of  tobacco  on  the  heart 
yet,  but  enough  is  knoA\Ti  to  make  it  certain  that  it 
causes  pali)itation,  irregular  rhythm,  and  cardiac  ar- 
terial sclerosis  with  fatal  angina  pectoris.  The  mode 
in  which  this  last  condition  is  brought  about  from  the 
tobacco  habit  is  not  certainly  known,  but  it  is  so  all 
the  same.  By  tobacco  habit  is  meant  not  one  cigar  or 
cigarette  a  day,  or  even  two.  Different  j)eople  are  dif- 
ferently affected  by  it.  One  or  two  cigars  per  day  is 
habit  for  some,  while  others  may  smoke  several,  besides 
chewing.  The  worst  cases  of  jjoisoning,  and  the  so- 
called  tobacco  hearts,  occur  among  tenement-house  girls 
in  this  city  who  make  cigars  or  cigarettes,  or  strip  to- 
bacco, as  it  is  called.  Especially  in  the  winter  does  this 
occur,  when  they  work  with  the  windows  closed  and 
are  inhaling  the  dust  and  fumes  of  tobacco.  Irregular 
rhythm,  palx)itation,  and  an^Emia  are  common  among 
those  girls.  Besides  tobacco,  there  are  the  poisons  of 
opium,  malaria,  and  also  of  syphilis,  lead,  gout, 
rheumatism,  and  Bright's  disease  of  the  kidneys. . 

(4)  MecJianical. — AYe  see  this  in  general  emphysema, 
where,  owing  to  obstruction  to  the  i)ulmonary  circula- 
tion, the  heart  becomes  tired,  and  not  only  becomes 
irregular  in  I'hythui  at  times,  l)ut  often  intermits  so  a« 
to  take  a  rest.  In  pressure  from  tight  lacing,  effusions 
from  pleui'isy,  in  jmeumothorax,  ovarian  and  other 
tumors,  i^regnancy,  jineurism,  and  such  like  causes,  the 
heart  may  palpitate,  or  intermit.     In  treating  these 


THE   SPIIYGMOGRAPH.  267 

symptoms,  therefore,  tlie  necessity  of  first  ascertaining 
the  cause  in  each  case,  with  a  view  to  its  removal,  if 
possible,  is  ?4Dparent. 

The  Sphygmograph. 

The  sphygmograph  is  an  instrument  used  in  obtain- 
ing graphic  representations  of  the  x^ulse.  In  like  man- 
ner the  cardiograph  is  used  with  regard  to  the  impulse 
of  the  heart.  Both  instruments  require  great  care  in 
their  use,  as  well  as  experience.  Much  time  is  often 
consumed  in  endeavoring  to  obtain  these  tracings,  and 
as  they  are  often  quite  unnecessary  in  making  a  diag- 
nosis such  instruments  are  not  likely  to  be  of  much 
value  to  the  average  practitioner.  A  few  remarks  re- 
garding the  sphygmograph  may  not,  however,  be  out 
of  place.  There  are  many  of  these  instruments  in  use, 
but  perhaps  Marey's  or  Dudgeon's  is  as  good  as  any. 
In  fact,  Dudgeon's  is  very  readily  applied,  more  so,  in 
my  experience,  than  any  of  the  rest.  According  to 
Walshe,  a  pulse  trace  consists  in  a  series  of  figures 
representing  the  successive  cardiac  circuits,  or  revolu- 
tions. 

Each  figure  consists  of  three  parts  for  consideration : 
(1)  the  percussion  stroke  (up-stroke,  line  of  ascent),  (2) 
the  apex,  and  (3)  the  downstroke  (line  of  descent). 
The  percussion,  or  upward  stroke  shows  the  force  and 
character  of  the  j)ulse  beat  during  ventricular  systole. 
The  apex  is  broad,  medium  or  sharply  pointed,  accord- 
ing as  the  pulse  is  more  or  less  sustained,  so  that  it  is 
broad  in  hypertrox)hy,  the  valves  being  perfect,  but 
jiointed  in  aortic  regurgitation.  Just  as  the  point  of 
the  tracer  falls  a  little,  it  rises  again,  forming  what  is 


268  PHYSICAL    DIAGNOSIS. 

termed  the  tidal  wave.  The  percussion-stroke  (up- 
stroke), the  apex,  and  the  tidal  wave  all  belong  to  the 
first  sound  and  systole.  Now  comes  the  first  period  of 
silence,  and  the  point  of  the  tracer  immediately  drops 
into  the  aortic  notch  at  the  same  time  that  the  second 
sound  is  jiroduced.  Then  follows  the  second  period  of 
rest,  corresponding  to  the  remainder  of  the  downward- 
stroke  (line  of  descent),  marked  first  by  the  dicrotic 
wave,  secondly,  sometimes  by  a  tricotic  wave,  or  if 
there  are  many  such  waves,  this  part  of  the  line  of  de- 
scent becomes  polycrotic,  or  tremulous.  Dicrotism,  as 
well  as  tricotism,  or  even  polycrotism,  is  due  simx)ly  to 
the  elastic  recoil  of  the  arteries,  and  need  not  be  due 
to  any  abnormal  condition,  especially  dicrotism.  With 
the  normal  pulse,  the  percussion  (up)  strokes  should  be 
of  the  same  length,  so  that  the  base,  or  respiration  line, 
as  it  is  called,  of  all  the  figures  should  be  even  and  hori- 
zontal, as  well  as  the  apex  line.  In  disease,  however, 
these  lines  are  subject  to  great  irregularity.  The 
sphygmographic  tracings  characteristic  of  various  car- 
diac diseases  are  given  at  the  time  of  describing  those 
diseases,  to  which  the  I'eader  is  referred. 

Aoinir  Aneitris.a[. 

The  aorta  is  divided  anatomically  into  three  parts: 
(1)  arch,  (2)  thoracic  aorta,  and  (3)  abdominal  aorta. 

The  arcli  consists  of  three  portions,  (1)  ascending,  (2) 
transverse,  and  (3)  descending  portion.  (1)  The  ascend- 
ing portion  of  the  arch,  about  two  inches  long,  arises 
from  the  upx)er  part  of  the  left  ventricje,  on  a  level 
with  the  lower  border  of  the  left  third  costal  cartilage, 
and  behind  the  left  edge  of  the  sternum,  behind  and  a 


AOKTIC    ANEURISM.  269 

little  beloAv,  as  well  as  to  the  right  of  the  origin  of  the 
l^ulmonary  artery  (p.  187).  It  passes  obliquely  upward 
and  to  the  right,  to  the  upx:)er  border  of  the  right 
second  costo-sternal  articulation.  A  needle  pushed 
into  the  second  interspace  on  the  right,  close  to  the 
right  edge  of  the  sternum,  would  penetrate  the  most 
prominent  bulge  of  this  portion  of  the  aorta,  and  hence 
this  siDace,  as  stated  before,  is  termed  the  aortic  inter- 
sj)ace.  (2)  The  transverse  portion  of  the  arch  com- 
mences at  the  upper  border  of  the  right  second  costo- 
sternal  articulation,  and  arches  from  right  to  left,  and 
from  before  backward,  in  front  of  the  trachea  and 
oesophagus,  to  the  left  side  of  the  body  of  the  third 
dorsal  vertebra.  (3)  The  descending  i)ortion  of  the 
arch  extends  from  the  left  side  of  the  body  of  the  third 
dorsal  vertebra  down  to  the  lower  border  of  the  left 
side  of  the  body  of  the  fourth  dorsal  vertebra. 

The  tlioracic  aorta  commences  at  the  left  lower  bor- 
der of  the  fourth  dorsal  vertelbra,  and  ends  in  front  of 
the  body  of  the  last  (twelfth)  dorsal  vertebra,  at  the 
aortic  oi^ening  in  the  diaphragm,  where  it  becomes 
abdominal. 

Tlie  abdominal  aorta  commences  at  the  aortic  oi^en- 
Ing  of  the  diaphragm,  in  front  of  the  body  of  the  last 
(twelfth)  dorsal  vertebra,  and  descending  a  little  to 
the  left  side  of  the  vertebral  column,  terminates  on  the 
body  of  the  fourth  lumbar  vertebra,  commonly  a  little 
to  the  left  of  the  median  line,  where  it  divides  into  the 
two  common  iliac  arteries  (Gray). 

Aneui'isni  signifies  a  dilatation.  According  to 
Walshe,  it  is,  in  its  widest  sense,  a  local  increase  of 
calibre  of  an  artery.     Aortic  aneurism,  therefore,  is  a 


270  PHYSICAL    DIAGNOSIS. 

local  increase  of  calibre,  or  a  dilatation  of  tlie  aorta  in 
some  j)art  of  its  course.  If  it  affect  tlie  aorta  in  any 
j)art  of  its  course  within  the  thorax,  it  is  termed  tho- 
racic aneurism,  whether  it  be  any  portion  of  the  arch, 
or  thoracic  aorta.  It  is  termed  abdominal  aneurism 
when  it  affects  the  abdominal  aorta  in  any  i)art  of  its 
course. 

Classification. — There  are  various  classifications  of 
aortic  aneurism,  but  the  simplest  is  always  the  best. 
There  are  two  classes,  (1)  dissecting  and  (2)  circum- 
scribed. (1)  Dissecting  aortic  aneurism  usually  be- 
longs to  old  age,  and  affects  both  sexes  alike.  It  is 
caused  by  weakening  and  rupture  of  the  internal  and 
middle  coats  of  the  artery  from  fatty  metamorphosis 
due  to  senile  decay.  Inasmuch  as  aneurism  is  said  to 
be  false  when  all  the  coats  of  the  artery  are  not  dilated 
but  some  are  ruptured  or  worn  through,  all  dissecting 
aortic  aneurisms  are  necessarily  also  false.  Dissecting 
aneurism  would  also  be  said  to  be  sacculated,  fusiform, 
and  the  like,  according  to  the  shape  assumed. 

(2)  Circumscribed  aortic  aneurism  is  usually  a  man's 
disease,  and  occurring  generally  at  middle  life  or  past. 
Four  fifths  of  the  cases  of  thoracic,  and  about  ninety 
per  cent,  of  abdominal  circumscribed  aneurism,  occur 
in  men  from  forty  to  fifty  years  of  age.  This  is  due  to 
the  difference  from  Avomen  in  the  mode  of  life  and 
occupation.  About  five  per  cent,  of  the  cases  occur 
before  thirty,  and  in  all  such  cases  observed  by  me 
there  has  been  a  clear  history  of  syphilis. 

Circumscribed  aneurism  may  be  false  or  true,  ac- 
cording as  to  whether  or  not  some  of  the  coats  have 
sustained  solution  of  continuity  from  some  cause.     Tlie 


AORTIC    ANEURISM.  271 

inner  and  middle  coats  usually  give  way  in  false  aneu- 
rism, so  that  the  sac  is  chiefly  formed  by  the  outer 
coat.  But  in  case  of  wounds,  the  outer  coat  may  yield, 
allowing  the  middle  coat  to  protrude,  gi^'ing  rise  to 
what  is  termed  hernial  false  aneurism.  If  all  the  coats 
are  ruptured,  from  wounds  or  disease,  a  diffuse  or,  bet- 
ter, consecutive  aneurism  may  result.  AVhen  due  to 
injury  they  usually  occur  in  the  case  of  smaller  vessels 
than  the  aorta,  since  in  the  latter  case  the  patient 
would  be  likely  to  bleed  to  death  before  the  aneurism 
could  be  formed.  Wherever  they  occur  they  usually 
become  circumscribed.  Other  varieties  are  fusiform, 
cylindrical,  or  globular.  Generally,  however,  circum- 
scribed aneurism  is  irregular  in  shape,  causing  it  to  be 
sacculated.  And  inasmuch  as  only  the  outer  coat  is 
often  left  to  form  the  sac  in  such  cases,  circumscribed 
sacculated  aneurism  is  also  usually  false.  In  the  fusi- 
form variety,  or  where  there  is  slight  and  regular  dila- 
tation, the  aneurism  is  not  infrequently  true. 

Etiology. — Two  classes  of  causes  favor  the  produc- 
tion of  aneurism:  (1)  increase  of  blood  pressure,  and  (2) 
diminution  of  resisting  power  in  the  walls  of  the  ves- 
sel. (1)  Increase  of  blood  pressure  is  caused  by  heavy 
lifting  or  straining,  occupations  necessitating  long- 
continued  effort,  comx^ensating  hypertrophy  of  the  left 
ventricle  in  aortic  regurgitation,  and  intemperance. 
The  course  of  the  artery  must  also  be  taken  into  con- 
sideration. The  pressure  will  not  be  so  great  at  any 
given  XDoint  in  an  artery  whose  course  is  straight  as  it 
would  be  when  the  artery  is  curved.  The  sharper  the 
curve  is  the  greater  will  be  the  pressure,  and  this  is 
always  directed  against  the  periphery.     This  is  remark- 


272  PHYSICAL    DIAGNOSIS. 

al)l;r  well  illustrated  in  cases  of  aortic  aneurism.  Of  880 
cases  collected  by  Sibson,  632  affected  the  arcli,  while 
only  71  occurred  in  the  thoracic  aorta,  which  is 
straight,  as  %Aill  be  fully  described  presently.  (2)  Tlie 
walls  of  the  artery  are  Aveakened  by  surgical  injuries, 
or  by  constitutional  disease  tending  to  produce  arteri- 
tis, inherited  or  acquired.  Of  these  causes,  syphilis 
stands  at  the  head  and  front.  Lead  poisoning  proba- 
bly comes  next.  Then  follow  gout,  rheumatism,  and 
renal  disease.  Sometimes  predisposition  to  aneurism 
seems  to  be  inherited,  so  that  it  Avill  be  handed  down 
from  parents  to  children  for  several  generations. 

Relative  Frequency  of  Site. — Of  880  cases  collected 
by  Sibson,  87  were  situated  in  the  sinuses  of  Valsalva, 
193  in  the  ascending  portion  of  the  arch,  140  in  the 
ascending  and  transverse  j^ortion  of  the  arch,  120  in 
the  transverse  portion  of  the  arch,  20  in  the  transverse 
and  descending  portion  of  the  arch,  and  72  in  the  de- 
scending portion  of  the  arch.  That  is  to  say,  of  880 
cases  of  aortic  aneurism,  632  occurred  in  the  arch 
alone.  Of  these,  420  cases  occurred  in  the  ascending 
portion,  140  in  the  transverse,  and  72  in  the  descending 
I)ortion  of  the  arch.  The  thoracic  aorta  was  affected 
in  only  71  cases,  and  the  abdominal  aorta  in  177. 

The  principal  reason  for  this  marked  difference  in 
the  frequency  of  aneurism  in  the  parts  of  the  aorta,  as 
just  given,  is  owing  to  the  course  which  the  vessel 
takes.  In  the  arch,  of  course,  and  especially  the 
ascending  and  transverse  portions,  the  blood  pressure 
is  much  greater  than  where  the  vessel  is  straight.  Not 
only  that,  but  the  arch  is  nearest  to  the  heart  to  re- 
ceive all  its  force.     In  the  descending  portion  of  the 


AOETIC    ANEURISM. 


278 


arcli  the  number  of  cases  was  only  72,  and  in  the  tho- 
racic aorta,  only  71,  both  on  account  of  the  straight 
course  of  the  vessel,  and  differing  only  by  one  case. 
But  when  we  come  to  the  abdominal  aorta  the  number 
rises  to  177.  Here  the  artery  is  much  more  exposed 
to  injury  than  it  is  in  the  thoracic  cavity.  Moreover, 
the  abdominal  aorta  is  subject  to  be  bent  on  itself,  or 


— AORW. — 


fincH  oF/laK7/f. 


632 


Tomj:, 


-  '77 


eso. 


Fig.  31.— Schematic  Diagi-am  of  Relative  Frequency  of  Site  of  Aortic  Aneurism. 

23ut  on  the  stretch,  or  twisted,  and,  in  a  word,  to  be 
changed  in  its  direction  with  every  movement  of  which 
the  body  is  susceptible.  In  heavy  lifting,  \\T?estling, 
the  performances  of  athletes,  and  the  effort  at  recover- 
ing one's  position  when  suddenly  thrown  off  the  bal- 
ance by  simple  accident,  all  iDut  a  strain  on  the  ab- 
dominal aorta,  the  habitual  reception  of  which  not 
only  tends  to  make  that  vessel  brittle,  but  often  is  the 

immediate  cause  of  abdominal  aneurism.     Bartholow 
18 


274  PHYSICAL    DIAGNOSIS. 

states  that  he  has  never  known  a  case  of  abdominal 
aneurism  that  could  not  be  directly  traced  to  some  act 
of  violence. 

Symptoms. — In  thoracic  aneurism  these  may  com- 
mence suddenly,  as  if  something  had  given  way,  but 
much  more  frequently  they  come  on  gradually,  with 
failing  health.  There  is  pain,  which  is  usually  fixed, 
but  radiating.  Pain  is  one  of  the  first  and  most  fre- 
quent symptoms  of  aortic  aneurism  in  any  part  of  the 
vessel.  It  may  and  often  does,  exacerbate  and  remit, 
but  it  is  usually  an  early  and  a  x^ersistent  symptom. 
It  is  usually  deep  seated,  extending  through  from 
before  back.  Instead  of  actual  i^ain  it  is  sometimes 
described  by  the  patient  as  a  feeling  of  soreness  limited 
to  a  small  area.  Besides  pain,  there  are  dyspnoea,  with 
more  or  less  hoarse,  stridulous  cough,  and  alteration 
of  voice.  The  dyspnoea  is  of  two  kinds,  (1)  constant 
and  increasing  and  also  (2)  paroxysmal.  The  constant 
and  increasing  dyspnoea  of  course  is  due  to  the  grow- 
ing aneurismal  tumor  pressing  upon  and  displacing 
imi)ortant  j)ortions  of  the  organs  of  respiration.  The 
paroxysmal  dyspnoea,  however,  occurs  in  three  ways: 
(1)  it  may  be  due  to  spasm  of  the  glottis,  owing  to  irri- 
tation of  the  recurrent  laryngeal  nerves  from  pressure 
of  the  aneurism;  (2)  paralytic  closure  of  the  glottis 
from  paralysis  of  these  nerves  from  pressure  of  the 
aneurismal  tumor;  and  (3)  pressure  on  the  trachea  with 
accumulation  of  mucus  at  that  point.  Paralytic  closure 
of  the  glottis,  due  to  pressure  from  the  tumor,  is  neces- 
sarily a  dangerous  and  often  fatal  symptom.  The 
greater  the  effort  at  inspiration,  the  more  completely 
are  the  walls  of  the  larynx  sucked  together.     Dys- 


AORTIC    AXEUKISM.  275 

phagia  from  i)ressiire  on  the  cpsophagus  is  not  common, 
but  headache  due  to  obstruction  to  the  return  circula- 
tion of  the  bhjod  is  not  infrequent.  Sometimes  there 
is  disordered  vision,  owing  to  the  change  produced  in 
the  size  of  one  or  both  pupils  from  i^ressure  by  the 
aneurismal  tumor  on  the  sym];)athetic  nerves.  One 
or  both  may  be  contracted  or  dilated,  according  as 
the  sympathetic  nerves  are  irritated  or  paralyzed. 
Slight  haemoptysis  is  of  ordinary  occurrence,  the  blood 
being  mingled  with  the  sputa.  This  slight  haemoptysis 
is  due  to  bronchial  congestion  or  pulmonary  irritation, 
and  is  totally  different  from  the  rush  of  blood  due  to 
ruj)ture  of  the  sac.  The  patient  gradually  loses  flesh 
and  often  has  a  careworn,  wearied  appearance.  We 
see,  therefore,  that  in  thoracic  aneurism,  inward  press- 
ure signs,  as  they  are  termed,  are  always  more  or  less 
prominent.  In  abdominal  aneurism,  on  the  other  hand, 
with  the  exception  of  pain,  which  is  present  here  as 
well  as  in  thoracic  aneurism,  there  are  very  few  symp- 
toms to  be  described  by  the  patient.  The  onset  of 
abdominal  aneurism  is,  however,  usually  sudden.  In- 
deed, Bartholow  states  that  in  all  the  cases  of  abdominal 
aneurism  observed  by  him,  the  onset  was  sudden  and 
definite,  and  traced  to  some  act  of  violence,  as  sudden 
lifting  of  a  heavy  weight,  wrestling,  falling,  or  the  like. 
Physical  Signs. — These  differ  according  to  the  part 
of  the  aorta  affected,  the  arch,  the  thoracic  aorta,  or 
the  abdominal  aorta.  We  wiU  therefore  consider  them 
in  their  regular  order. 


276  PHYSICAL    UIAGjS^OSIS. 

I.  The  Arch  of  the  Aorta. 

Inspection. — At  lirst,  inspection  may  be  purely  nega- 
tive. But  after  the  aneurismal  tumor  has  become  suffi- 
ciently increased  in  size,  a  local  bulging,  or  pulsating 
tumor,  synchronous  in  its  pulsations  mtli  the  heart's 
systole,  is  usually  observed  at  the  right  edge  of  the 
sternum  in  the  second  intersi)ace,  when  the  ascending 
portion  of  the  arch  is  affected.  This  is  by  far  the  most 
common  site  for  aneurism  of  the  arch,  since  the  ascend- 
ing portion  is  most  frequently  affected.  The  tumor 
gradually  increases  downward  to  the  right,  pushing 
the  apex  of  the  heart  downward  and  to  the  left.  If  the 
transverse  portion  of  the  arch  is  affected,  the  tumor 
may  push  forward  the  top  of  the  sternum.  Or  it  may 
appear  on  the  left  of  the  sternum,  or  at  the  base  of  the 
neck,  according  to  the  x3ortion  of  the  arch  affected,  and 
other  circumstances.  Pulsation  may  sometimes  be 
noticed  even  in  the  interscapular  region  of  the  left 
Bide,  if  the  descending  portion  of  the  arch  be  affected. 
The  aneurismal  tumor  does  not  always  i)ulsate.  This 
occurs  when  the  sac  is  filled  to  a  great  extent  with 
fibrin,  through  which  a  small  stream  of  blood  flows, 
and  especially  if  the  descending  portion  of  the  arch  be 
affected  and  the  heart  is  weak.  If  the  aneurism  press 
on  the  superior  vena  cava,  there  will  be  enlargement  of 
the  veins  on  both  sides  of  the  neck,  with  more  or  less 
lividity  of  the  face.  But  if  the  tumor  press  on  one 
innominate  vein  only,  enlargement  of  the  veins  and 
lividity  of  the  face  will  be  observed  on  the  correspond- 
ing side  only.  Tlie  patient  is  not  infrequently  observed 
to  have  lost  somewhat  in  flesh. 


THE   ARCH   OF   THE   AORTA. 


277 


Palpation. — Two  centres  of  iDiilsation,  synchronous 
with  systole,  are  usually  felt,  one  due  to  the  impulse 
of  the  heart,  the  other  to  the  aneurism.  The  pulsation 
caused  by  the  aneurism  is  usually  accompanied  by 
thrill,  unless  the  sac  is  greatly  filled  with  fibrin.     In 


Fig.  32. — Aneurism  of  Ascending  Portion  of  Arch  in  a  German  woman,  set.  48. 
Death  from  Ruptm-e  into  Pericardial  Sac. 

that  case,  thrill  may  be,  and  usually  is,  entirely  absent. 
Indeed,  in  these  cases,  also,  the  systolic  impulse  of  the 
tumor  may  be  so  feeble  that  it  can  scarcely  be  observed. 
In  aneurism  of  the  transverse  portion  of  the  arch  the 
pulse  is  weaker  at  the  left  wrist,  and  on  the  left  side  of 


278  PHYSICAL    DIAGNOSIS. 

the  liead  and  neck,  than  the  right.  This  was  beauti- 
fully illustrated  in  a  i)atient  recently  examined  at  my 
request  by  Drs.  Edward  G.  Janeway,  Francis  Delafield, 
Alfred  L.  Loomis,  and  John  A.  Wyeth,  of  this  city. 
The  patient  was  sent  to  Mt.  Sinai  Hospital,  where  Dr. 
Wyeth  ligated  the  left  common  carotid  and  left  sub- 
clavian arteries  with  every  prospect  of  success,  but  the 
patient  unfortunately  died  of  pneumonia  and  syphilitic 
pulmonary  dex)Osits.  Post-inortem  examination  showed 
the  absolute  accuracy  of  the  diagnosis  of  aneurism  of 
the  transverse  portion  of  the  arch  extending  to  the  Junc- 
tion of  the  descending  portion.  There  was  no  dysphagia, 
but  the  aneurismal  sac,  tilled  with  fibrin,  was  adherent 
to  the  trachea  for  about  an  inch  and  a  half,  causing 
most  distressing  dyspnoea.  In  these  cases,  as  also  hap- 
pens sometimes  in  aneurism  of  the  descending  portion 
of  the  arch,  the  i:)ulsation  of  the  aneurism  may  be  felt 
in  the  suprasternal  notch  by  pressing  the  finger  well 
down  into  it  mtli  the  patient's  head  bent  forward. 
The  vocal  fremitus  over  the  tumor  is  usually  dimin- 
ished or  absent,  according  to  the  size  of  the  aneurism 
and  displacement  of  lung  tissue.  Pressure  on  a  large 
bronchial  tube  also  may  so  obstruct  the  convection  of 
the  voice  sound  that  the  vocal  fremitus  may  be  entirely 
absent  over  the  corresponding  area. 

Percussion. — This  should  be  gently  performed  over 
the  tumor,  otherwise  it  causes  great  suffering  to  the 
jiatient,  to  say  nothing  of  the  danger  of  rupture  of  the 
aneurismal  sac.  For  this  reason  auscultatory  percus- 
sion is  the  best  method,  since  it  is  performed  very  gent- 
ly. Dullness  is  elicited  over  and  immediately  around 
the  tumor,  and  the  dullness  will  be  marked  in  propor 


THE   AECH   OF   THE   AORTA.  279 

tion  to  the  size  and  locality  of  the  tumor.  If  it  be 
small  and  deep  seated,  the  quality  of  the  percussion 
note  may  be  very  little  changed.  On  the  other  hand, 
if  the  tumor  be  large  and  superficial  the  quality  may 
be  nearly  or  quite  flat.  It  is  of  great  importance  to 
observe  whether  the  dullness  extends  continuously 
out  toward  the  acromial  angle,  over  pulmonary  tissue, 
or  across  the  median  line.  The  latter  sign  would  be  a 
sure  indication  of  the  presence  of  a  tumor  of  some  sort 
in  the  mediastinum.  If  the  descending  or  transverse 
portions  of  the  arch  be  affected,  but  especially  the  de- 
scending, dullness  on  percussion  may  be  obtained  in 
the  interscapular  region  of  the  left  side. 

Auscultation. — The  aneurismal  sounds  usually  pres- 
ent are  most  audible  directly  over  the  tumor.  The 
aneurismal  systolic  shock  is  usually  accompanied  by  a 
bruit,  or  murmur,  w^hich  is  louder  than  the  heart  sounds 
and  usually  lower  in  pitch,  especially  when  blowing  in 
quality.  The  bruit  or  murmur  may,  however,  be  rasx3- 
Ing  or  filing  in  quality,  and  then  the  pitch  may  be  high. 
Sometimes  it  is  roaring  or  whistling. 

Besides  the  systolic  bruit,  there  may  be  also  a  dias- 
tolic murmur,  wdiich  is  usually  softer  than  the  first,  and 
causing  with  it  the  to-and-fro  sound.  The  aneurismal 
bruit  is  usually  heard  in  front,  but  it  is  sometimes  even 
heard  posteriorly,  in  the  interscapular  space  of  the  left 
side,  if  the  descending  portion  of  the  arch  be  affected. 
There  is  diminution  or  absence  of  the  respiratory  mur- 
mur over  the  tumor,  and  pressure  on  a  bronchial  tube 
may  produce  atelectasis  for  a  corresjponding  area  of 
pulmonary  tissue  (see  p.  60).  Owing  to  the  i:)resence 
usually  of  secondary  localized  bronchitis  and  a  little 


280  PHYSICAL    DIAGNOSIS. 

solidified  lung  tissue  from  pressure  or  local  inflamma- 
tion near  the  tumor,  rales,  bronchial  breathing,  bron- 
chox)hony,  and  increased  vocal  fremitus  over  a  corre- 
sponding small  area,  may  be  obtained. 

Diagnosis. — To  differentiate  between  aneurism  of 
the  three  portions  of  the  arch  we  must  bear  in  mind, 
first,  that  the  ascending  portion  is  by  far  more  fre- 
quently afl'ected  than  the  others,  the  transverse  portion 
being  next  in  order,  and,  lastly,  the  descending  portion. 
When  the  ascending  portion  of  the  arch  is  the  seat  of 
the  aneurism,  the  tumor,  as  already  stated,  usually  ax3- 
pears  in  the  second  interspace  at  the  right  edge  of  the 
sternum,  and  gradually  increases  downward  to  the 
right,  pushing  the  apex  of  the  heart  downward  and 
to  the  left.  Occurring  in  the  transverse  portion,  it 
j^ushes,  the  manubrium  forward  or  appears  at  the  left 
of  the  sternum. 

Aneurism  of  the  transverse  jDortion  of  the  arch  causes 
a  weaker  pulse  at  the  left  wrist  and  on  the  left  side  of 
the  head  and  neck  than  on  the  right,  with  pulsation  in 
the  suprasternal  notch,  and  sometimes  dullness  on 
percussion,  even  in  the  interscapular  region  of  the  left 
side.  Pressure  on  the  trachea  and  oesophagus  is  more 
marked  in  these  cases  also.  In  case  of  aneurism  of  the 
descending  portion  of  the  arch  of  the  aorta,  there  are 
pain  in  the  interscapular  region  of  the  left  side,  dull- 
ness on  j)ercussion;  and  sometimes  a  pulsation  is  ob- 
served there,  with  a  bruit  on  auscultation.  Pulsatiofi 
may  also  be  sometimes  felt  in  the  suprasternal  notcli 
from  aneurism  of  the  descending  portion  of  the  arch, 
but  not  so  distinctly  as  when  the  transverse  portion  is 
affected. 


THE    ARCH    OF   TJIE    AOIITA.  281 

Arteria  Innominata. — Aneurism  of  this  vessel  pul- 
sates behind,  or  above,  the  inner  part  of  the  clavicle, 
causes  weaker  pulse  on  the  right  side  than  the  left, 
and  is  rarely  attended  with  dysphagia  or  tracheal 
pressure,  but  more  frequently  with  pain  or  paralytic 
symptoms  in  the  right  arm.  Pulsation  of  this  aneur- 
ism diminishes  or  ceases  from  compression  beyond  the 
tumor. 

Consolidation  of  pulmonary  tissue  from  phthisis  or 
syphilis,  would  give  rise  to  dullness,  which,  however, 
would  extend  outward  to  the  acromial  angle,  but  not 
across  the  median  line.  There  would  also  be  wanting 
the  inward  pressure  signs  of  aneurism.  In  the  case  of 
suspected  pulmonary  syphiloma,  the  failure  of  i:)roper 
antisyphilitic  treatment  would  rather  favor  the  i^res- 
ence  of  aneurism. 

Cancer  of  lungs  may  be  associated  with  cancer  of  the 
mediastinal  glands,  Avhich,  becoming  enlarged,  would 
give  rise  to  dullness  that  extended  across  the  median 
line.  But  infiltrated  cancer  causes  retraction  of  the 
chest  walls  instead  of  bulging,  and  there  are  no  inward 
pressure  signs.  The  cancerous  cachexia  and  appear- 
ance of  cancer  elsewhere  would  establish  the  diagnosis. 

Mediastinal  tumors  are  the  most  difficult  to  differ- 
entiate. But  unless  associated  with  infiltrated  cancer 
of  the  lungs  or  elsewhere,  they  usually  occur  in  women 
under  twenty-five,  which  aneurism  rarely,  if  it  ever 
does.  Such  tumors  are  usually  also  associated  with 
currant-jelly  (cancerous)  expectoration,  distention  of 
the  siiperficial  veins  on  the  chest,  sometimes  oedema  of 
the  chest  and  arm,  and  they  may  also  exist  elsewhere. 

Conrctation  and  stricture  of  the  .aorta  will  o-ive  rise 


282  PHYSICAL    DIAGNOSIS. 

to  a  systolic  murmur,  but  they  cause  no  bulging  to  be 
observed  on  inspection,  no  dullness  on  j)ercussion,  and 
no  pressure  signs.  They  usually  result  from  syphilis, 
and  coarctation  is  sometimes  a  congenital  malforma- 
tion. 

Pulsating  empyema  is  easily  distinguished  by  the 
equality  of  the  radial  pulse,  the  absence  of  murmurs 
and  thrill,  as  well  as  of  tracheal,  oesophageal,  and 
laryngeal  symi^toms.  It  might  occur  to  the  j)ractitioner 
to  explore  with  a  fine  needle  in  order  to  set  the  ques- 
tion at  rest,  but  this  should  not  be  done  unless  abso- 
lutely necessary,  which  is  rarely  the  case,  since  emboli 
might  be  detached  which  would  prove  to  be  trouble- 
some, if  not  fatal. 

Pericardial  effusion  gives  rise  to  prominence  of  the 
precordial  region,  with  more  or  less  dyspnoea  some- 
times, and  marked  dullness  on  percussion;  but  the 
area  of  dullness  is  somewhat  triangular,  with  the  base 
down,  aneurism,  perhaps,  never. 

Subperiosteal  abscess  of  the  sternum  may  cause  some 
prominence  of  the  sternum,  with  dullness  on  percus- 
sion, but  the  inward  j^ressure  signs  and  all  other  signs 
of  aneurism  are  wanting. 

Cardiac  hypertrophy  causes  only  one  centre  of  mo- 
tion ;  Avhen  aneurism  is  j)resent  there  are  usually  two. 
The  aneurism  may  be  situated,  however,  very  close 
to  the  heai-t,  and  associated  with  aortic  regurgitation 
and  enlargement  of  the  left  ventricle.  The  absence  of 
pressure  signs  and  the  presence  of  drojDsy  both  fa^•or 
cardiac  disease.  In  aol'tic  regurgitation,  also,  the  pulse 
characteristic  of  that  disease,  and  felt  equally  at  both 
wrists,  would  l)e  against  aneurism. 


thoeacic  aorta.  283 

11.  Thoracic  Aorta. 

Aneurism  of  the  thoracic  aorta  is  not  so  easily  recog- 
nized as  when  it  occurs  in  the  ascending  and  transverse 
portions  of  the  arch.  From  a  number  of  cases  reported 
by  Deputy-coroner  Jenkins,  of  this  city,  and  referred 
to  by  Dr.  H.  M.  Biggs  in  a  very  interesting  paper  on 
this  subject,  read  before  the  Section  in  Practice,  New 
York  Academy  of  Medicine,  in  February,  1888,  it  ap- 
pears that  not  infrequently  the  cause  of  sudden  death 
was  due  to  rupture  of  unsuspected  aneurism  of  the 
thoracic  aorta.  Owing  to  the  position  of  the  vessel, 
the  i)hysical  signs  are  referable  to  the  left  side  of  the 
spinal  column  rather  than  the  right,  though  an  excep- 
tion to  this  rule  is  rarely  met  with.  Pain  in  this  case, 
as  elsewhere,  is  one  of  the  symptoms,  and  usually  con- 
sists of  a  gnawing  sensation  felt  in  the  dorsal  vertebrae. 
These  may  become  eroded  in  time,  and  give  rise  to 
curvature  of  the  spine.  Bulging  in  a  few  cases  may  be 
noticed  posteriorly,  but  dullness  on  jDercussion,  over  a 
circumscribed  area,  corresponding  to  the  aneurism,  is 
much  more  frequent.  On  auscultation  a  bruit  may  be 
heard,  but  is  often  absent.  Owing  to  want  of  physical 
signs  the  aneurism  often  escapes  detection,  as  already 
stated.  Laryngeal  symptoms  are,  of  course,  usually 
wanting,  but  there  may  be  dysphagia  from  pressure  on 
the  oesophagus.  The  disease  may  be  mistaken  for 
pleurisy  with  effusion  in  some  instances,  so  that  the 
exploring  needle  alone  could  enable  one  to  distinguish 
between  them. 


284  PHYSICAL    DIAGNOSIS. 

III.  Abdominal  Aorta. 

The  symptoms  in  this  case  have  reference  to  pressure 
on  abdominal  organs.  Pain,  as  in  aneurism  elsewhere, 
is  one  of  the  first  symx3toms.  It  may  be  local,  or  it 
may  extend  along  the  branches  of  the  lumbar  j)lexus. 
Jaundice  from  pressure  on  the  bile  duct  is  not  common, 
but  sometimes  occurs.  Changes  in  the  urine  from 
pressure  on  the  renal  vessels  is  even  more  rare.  But 
nausea  and  vomiting  are  not  infrequent,  due  to  press- 
ure against  the  stomach. 

Insx>ecUoii. — This  is  usually  negative  in  its  results, 
but  in  case  of  an  emaciated  j)atient,  pulsation  of  the 
tumor  may  be  visible  in  the  recumbent  dorsal  position. 

Palpation. — A  pulsating  tumor  is  usually  felt  some- 
what to  the  left  of  the  median  line.  The  XDulsation  is 
synchronous  with  the  cardiac  systole,  and  is  described 
as  expansile  in  character — that  is,  it  exjDands  in  all 
directions  under  the  grasp  of  the  hand.  Thrill  may 
also  be  present.  Some  authors  describe  this  pulsation 
as  post  systolic,  or  coming  just  after  the  systole  of  the 
heart.     Others  regard  it  as  purely  systolic. 

Percussion. — If  the  tumor  is  of  considerable  size 
there  is  dullness  on  percussion.  But  this  is  the  least 
constant  physical  sign,  owing  to  the  presence  of  gas  in 
the  neighboring  viscera. 

Auscidtatlon. — A  systolic  bruit  may  or  may  not  be 
present  here  as  elsewhere.  If  the  tumor  be  well  filled^ 
with  fibrin  there  Avill  be  no  bruit.  Diastolic  bruit  is 
rare,  but  when  present  is  thought  to  be  diagnostic  of 
the  presence  of  aneurism. 

Pulsation  of  the  abdominal  aorta  may  be  mistaken 


ABDOMINAL   AOliTA.  285 

for  abdominal  aneurism.  But  in  the  former  case  the 
pulsation  will  be  along  the  course  of  the  vessel,  giving, 
under  palpation,  the  sense  of  a  pulsating  cord  rather 
than  an  expansile  tumor.  The  fact  that  such  jjulsa- 
tions  of  the  aorta  usually  occur  in  young  and  nervous 
women  with  thin  abdominal  walls,  rather  than  in 
middle-aged  men,  also  is  against  aneurism. 

Pulsating  tumors  may  also  simulate  aneurism  and 
be  even  accompanied  by  a  bruit.  But  by  placing  the 
patient  in  the  knee-chest  position  the  pulsation  at  once 
ceases  if  it  be  not  aneurism,  since  the  tumor  simply 
gravitates  away  from  the  aorta  and  no  longer  has  its 
pulsations  imparted  to  it.  In  case  of  a  young  hysteri- 
cal Avoman,  recently  examined  by  me  at  the  Polyclinic, 
there  was  a  distinct  pulsating  tumor  felt  over  the  ab- 
dominal aorta.  The  pulsation  immediately  ceased  in 
the  knee-chest  position,  and  as  she  gave  the  history  of 
constiiDation,  I  concluded  that  it  was  a  case  of  impacted 
faeces.  A  dose  of  castor  oil  confirmed  the  diagnosis,  by 
causing  a  large  evacuation  of  the  bowels  and  disap- 
pearance of  the  tumor.  In  this  case  I  may  add  that 
the  tumor  had  a  distinctly  boggy  feeling,  and  was  not 
expansile,  but  simjply  thumping  under  palpation. 


THE  END, 


Il^DEX. 


Abdominal  aorta,  284. 

respiration,  9. 
Abscess  of  the  lungs,  89. 
Accentuation  of  heart  sounds, 

211. 
Acute  miliary  tuberculosis,  107. 
Adventitious  sounds,  37. 
Adhesions,  pleuritic,  146. 
^gophony,  127,  145,  179. 
Amphoric        (jug,       metallic) 
breathing,  126,  176. 

echo,  180. 

resonance,  124. 

tinkle,  128,  158,  165. 

voice,  180. 
Ansemic  murmurs,  228,  237. 
Aneurism  of  aorta,  268. 

of  the  heart,  362. 
Angina  pectoris,  257. 
Anterior  region,  2. 
Anthrakosis  pulmonum,  87. 
Aorta,  187. 
Aortic  interspace,  190. 

murmurs,  222. 

obstruction,  223. 

and  regurgitation,  235. 

regurgitation,  232. 

valves,  188. 
Apex  murmurs,  197. 
Apices  affected  by  tubercle,  113. 
Apneumatosis,  59. 
Apoplexy,  pulmonary,  99. 
Arch  of  aorta,  276. 
Aspiration,  151. 

time  for,  141. 


Aspirator,  Potain's,  150. 
Areas  of  cardiac  dullness,  185. 
Asthma,  42. 
Atelectasis,  59. 
Atrophous  emphysema,  49. 
Atrophy  of  the  heart,  252. 
Auenbrugger,  16. 
Auscultation,  25. 
Auscultatory  percussion,  33. 
Autophonia,  34. 
Axillary  line,  8. 
region,  7. 

Bacillus,     Koch's     tubercle, 

106,  110,  117,  130,  134. 
Barry,  71. 

BasedoAv's  disease,  253. 
Bell-metal  resonance,  128. 
Bigemenny,  264. 
Blood-currents,  186. 
Bronchi,  division  of  primitive, 

14. 
Bronchial  breathing,    79,    119, 
175. 
hemorrhage,  101. 
respiratory  murmur,  nor- 
mal, 28. 
rales,  37,  162. 
Bronchitis,  35. 

Bronchiloquy,  80,  127.  178,  181. 
Bronchophony,  80,  120,  145. 
Broncho-cavernous  breathing, 

126. 
Broncho-pneumonia,  84 
Bruit  de  diable,  230. 


288 


IjS^DEX. 


Calormetatiox,  8. 
Camraan,  25. 
Cancer  of  the  lungs,  90. 
Capillary  bronchitis,  39. 
Cardiac  aneurism,  262. 

dropsj',  253. 

dullness,  185. 

murmurs,  195. 

thrill,  202. 
Cardio-respiratory     murmurs, 

209,  228. 
Catarrhal  phthisis,  107,  113. 

pneumonia,  84. 
Cavernous  breathing,  125,  145, 

176. 
Caverno-bronchial    breathing, 

126. 
Cavernous  voice,  179. 
Cavities,  121-130., 
Chronic  pneumonia,  87,  134. 
Circulation,  186. 
Clavicular  resonance,  22. 
Cog-wheeled  respiration,  27. 
Cohnheim,  96. 

Compensatory  emphysema,  48. 
Congestion  of  the  lungs,  63. 
Congress  at  Paris,  report  on, 

108. 
Consumption  of  the  lungs,  106. 
Cracked-pot  resonance,  123. 
Crepitant  rales,  76,  163. 
Croui>ous  pneumonia,  70. 
Cyanosis,  237. 

Dilatation  of  the  heart,  195, 

249. 
Divided  respiratory  murmur, 

173. 
Dry  pleurisy,  137. 

rales,  159. 
Duration  of  sound,  20. 
Dynamic  nmrmurs,  207,  227. 
Dyspnoea  in  emphysema,  51. 

ECHINOCOCCI,  105. 

Effusion,  aspiration  for,  150. 


Eichhorst,  60. 
Elements  of  sound,  18. 
EmboUsm,  97. 
Emphysema,  47. 
Empyema,   153. 
Endocardial  murmurs,  196. 
Endocarditis,  193,  240. 
Exophthalmic  goitre,  2.53. 

Fatty  heart,  250. 
Fibrosis  of  the  heart,  262. 
Fibroid  phthisis,  107,  131, 
First  sound  of  the  heart,  190. 
Flatness,  129. 
Fox,  Dr.  Wilson,  71. 
Fremitus,  11. 
Freund,  50. 
Friction  fremitus,  12. 
Frictio  redux,  141. 
Friction  sounds,  140,  169. 
Functional    cardiac    diseases, 
263. 

Gangrene  of  the  lungs,  89. 
Gravity    of    valvular    lesions, 

/iOO. 

Graves'  disease,  253. 
Grisolle,  71. 
Gurgles,  128,  165. 

H^Mic  murmurs,  237. 
Hsemopericarditis,  244. 
Haemoptysis,  100. 
Hsemothorax,  154. 
Hay  fever,  42. 
Heart,  183. 

diseases,      sudden     death 
from,  260. 

displaced  in  phthisis,  121. 

in  emphy.sema,  53. 
Hemorrhage  from  the  lungs, 

102,  117. 
Hemorrhagic  consumption,  107. 

infarction,  96. 
Hydatids  of  the  lungs,  105. 
Hydro-pericardium,  244. 


INDEX. 


289 


Hydro-pericarditis,  244. 
Hydrothorax,  153. 
Hydro-pneuuio  (pyo-)  thorax, 

157. 
Hypertrophy  of  the  heart,  195, 

245. 
Hyi^ertrophous     emphysema, 

49. 
Hypochondriac  region,  4. 
Hypostatic  congestion,  64. 
pneumonia,  72. 

Indeterminate  rales,  129,168. 
Infarction,  9fi. 
Infantile  pneumonia,  84. 
Infra-axillary  region,  7. 

clavicular  region,  5. 

mammary  region,  4. 

scaiaular  region,  6. 
Inspection,  8. 
Intermittent  pulse,  2G4. 
Inter-scapular  region,  5. 
Intra-arterial  murmurs,  226. 

plural  rales,  39, 129, 140, 166. 

ventricular  murmurs,  206, 
226. 
Irregular  rhythm  (heart),  264. 

jjulsation,  219. 

Koch's  tubercle  bacillus,  108. 
as  an  aid  to  early  diagno- 
sis, 110,  117,  130. 

Laennec,  25. 
Laryngeal  breathing,  28. 

phthisis,  107. 
Lateral  regions  of  the  chest,  7. 
Lobar  pneumonia,  69. 
Lobular  pneumonia,  84. 
Loomis,  71,  278. 

Mammary  region,  4. 
Mammillary  line,  8. 
Marasmic  atelectasis,  60. 
Mensuration,  32. 
Metallic  tinkle,  128,  158,  165. 


Mitral  obstruction,  209. 

regurgitation,  198. 

and  obstruction,  217, 

regurgitant  pulse,  200. 
Moist  rales,  161. 
Mucous  rales,  38,  162. 
Mueo-crepitant  rales,  163. 
Mucous  click,  164. 
Murmurs  of  the  heart,  195, 
Musical  heart  murmurs,  203. 
Myocarditis,  244. 
Myoidema,  114. 

NoRMAii  respiratory  murmur, 
26,  170,  172. 

vesiculo-bronchial  breath- 
ing, 28. 

vesicular  resonance,  18. 

vocal  resonance,  13. 

(Edema  of  the  lungs,  66. 
Operation  for  aspiration,  151, 
Outline  of  the  heart,  184. 

Palpation,  10. 
Palpatory  percussion,  17. 
Palpitation  of  the  heart,  263. 
Paracentesis  thoracis,  33. 
Parasternal  line,  8. 
Pectoriloquy,  126,  180. 
Pectorophony,  29,  177. 
Percussion,  16. 
Pericardial  sounds,  241. 
Pericarditis,  241. 
Physical  diagnosis,  1. 

signs,  1. 
Phthisis,  106. 
Phonometry,  34. 
Piorry,  17, 
Pitch  of  sound,  18. 
Pleurisy  a  cause  or  result  of 
phthisis  ?  Ill,  138. 

classification  of,  136. 
Pleurae,  boundaries  of,  136, 

function  of,  136. 
Pleurisy,  article  on,  135. 


290 


INDEX. 


Pleurisy,  dry,  137. 

acute  with  effusion,  138. 

subacute,  chronic,  141. 
Plexinietev,  17. 
Pneumonia,  69. 

lobular,  84.  "" 

inter-loVmlar,  87. 
Pneunio-hy(lrf>thorax,  156. 
Pneuniothovax,  154. 
Pneuuionokoniosis,  88. 
Posterior  regions  of  the  chest,  5. 
Puerile  respiration,  2.9,  171. 
Pulmonary  apoplexy,  99. 

collapse.  59. 
'  consvniiption,  106. 

congestion,  Co. 

hemorrhage,  102. 

interspace,  190. 

(artery)  murmurs,  236. 

oedema,  66. 

obstruction,  236. 

regurgitation,  239. 
Pulse,  intermittent,  264. 
Purring  thrill,  202. 
Puncture  in  pleurisy,  151. 
Pyo-pneumothorax,  157. 

QUAlN's  fatty  heart,  250. 
Quality  of  sound,  18. 

Rales  (rhonchi),  37,  160. 
Rale  redux,  81. 
Reduplication  of  heart  sounds, 

211. 
Regions  of  the  chest,  2. 
Regional  percussion,  21. 
Respiratory  percussion,  20,  149. 
murnuir,  normal,  27. 
changes  in,  170,  176. 
Rlionchal  fremitus,  12. 
Rhythm  of  the  heart,  192. 

irregular,  264. 
Rude  respiration,  116,  175. 

Scapular  line,  8. 
region,  5. 


Scrofula,  relations  to  tubercle, 
112. 

Sibilant  rales,  37,  160. 

Siderosis  pulmonum,  87. 

Skodaic  resonance,  78,  144. 

Sonorous  rales,  37,  160. 

Sounds  of  the  heart,  190,  192. 

Splashing  sounds,  169. 

Sphygmograph,  267. 

Sputa,  8. 

Steam-tug  heart  murmurs,  234. 

Sternal  line,  3,  8. 

Stethoscopes,  24,  25. 

Stokes,  115. 

Stridor,  160. 

Stridulous  breathing,  160. 

Sub-axillary  region,  8. 

Sub-clavicular  region,  2. 

Sub-crepitant  i-ales,  38,  162. 

Sub-scapular  region,  5. 

Sub-mucous  rales,  38,  162. 

Sub-mammary  region,  4. 

Succussion,  33,  157,  169. 

Sudden  death  from  heart  dis- 
ease, 260. 

Summary  of  signs  in  health,  30. 

Superficial  veins,  121. 

Superior  costal  respiration,  9. 
sternal  region,  5. 

Supra-clavicular  region,  2. 

Supra-scapular  region,  5. 

Supra-sternal  region,  5. 

Tait,  Dr.  Lawsox,  115 
Thermometry,  8. 
Thickened  pleura,  146. 
Thoracentesis,  33. 
Thoracic  aneurism,  283. 
Thrill,  purring,  202. 
Thrombosis,  97. 
Tinkle,    metallic     (amphoric), 

128,  158,  165. 
Tobacco  heart,  258,  259,  266. 
Tracheal  rales,  162. 
Trachiloquy,  182. 
Tricui<i)id  obstruction,  221. 


INDEX. 


291 


Tricuspid  regurg^itation,  223. 
Tubercle  bacillus,  110,  117. 
Tubercular  consumption,  106. 
Tussile  fremitus,  12. 
Tympanitic  resonance,  124 

Valves  of  the  heart,  188. 
Valvular  lesions,  192. 
Venous  hum,  230. 
Vertebral  line,  8. 
Vesicular  rale,  164. 

respiratory  murmur,  27. 
Vesiculo-bronchial  breathing, 
28. 


Vesicular  emphysema,  43. 

resonance,  18. 
Vicarious  emphysema,  48. 
Vocal  fremitus,  11. 

resonance,  29. 

Wavy    respiratory    murmur, 

27,  174. 
Webster,  Dr.  David,  262. 
Wintrich,  17. 
Wyeth,  Dr.  John  A.,  278. 

Zenker,  87. 


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